Red Rocks Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gallup, New Mexico.
- Location
- 3720 Church Rock Street, Gallup, New Mexico 87301
- CMS Provider Number
- 325070
- Inspections on file
- 23
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Red Rocks Care Center during CMS and state inspections, most recent first.
Surveyors identified widespread environmental deficiencies, including strong, persistent urine and feces odors in multiple halls and rooms; broken, uneven, and cracked floor tiles; separated baseboards with visible black substances; and unsealed heating/cooling units with visible daylight and wall cracks. Numerous resident rooms had damaged bathroom doors and frames, missing trim, puncture holes with splintered edges, unfinished yellow foam sealant along baseboards, and broken or dirty fixtures. Resident furniture such as dressers, drawers, wardrobes, and chairs was in disrepair, with loose or missing handles, doors off hinges, and torn upholstery. Common areas, including the main dining room and hallways, had broken light fixtures with missing covers and hanging tape, cracked walls and ceilings, dirty vents with black mold-like buildup, unpainted patchwork, and scuffed exit doors, all contributing to an unsafe and uncomfortable environment.
The facility failed to accurately complete PASRR Level I screenings for multiple residents with mental health conditions. In several cases, residents with documented major depressive disorder, PTSD, anxiety disorder, or use of antidepressants had PASRR forms where the mental illness identification section was left blank or marked as "not identified." One resident’s depression screening (PHQ-9) was also incomplete and lacked a score. The Admission Director stated that the admissions department was responsible for PASRR completion, acknowledged some screenings were incorrect due to unanswered questions, and in other cases was unaware of residents’ documented psychiatric diagnoses while considering the PASRRs to be correct.
A resident returned from the hospital with a documented right scapular spine fracture with nonunion, instructions to wear a sling, obtain orthopedic follow-up, and be monitored for pain and mobility changes. The facility’s policy requires the IDT to revise the person-centered care plan after a change in condition, but the resident’s care plan was not updated to include the fracture diagnosis, immobilization interventions, transfer and mobility assistance, or pain-specific interventions. A CNA reported the resident was supposed to use a sling but did not consistently do so and continued to push up with the injured arm, and also reported receiving no care plan direction or training on sling use or mobility precautions. The ADM stated the care plan should have been revised after the hospital stay and that the DON was responsible for ensuring updates, while the MD stated he was aware of the fracture and expected hospital recommendations to be followed and care planned.
Surveyors identified that medication management practices were not followed, including incomplete temperature logs for the medication refrigerator over several months and undated insulin pens stored on a medication cart for multiple residents. An RN acknowledged that insulin pens were not dated at first use or with a 28-day discard date and stated that undated pens are considered expired. The DON confirmed that fridge temperatures were expected to be recorded once per shift but this was not done, and also confirmed that undated insulin pens are considered expired and should not remain in the carts.
Surveyors identified multiple infection control failures, including a medication aide not performing hand hygiene between residents, two residents with Foley catheters whose tubing was observed dragging on the floor, and residents on Enhanced Barrier Precautions (EBP) not receiving care consistent with the facility’s EBP policy. For residents with indwelling devices and a surgical wound, EBP signage was posted but staff, including RNs and the ADON, provided high-contact care without required PPE and expressed uncertainty about EBP requirements. In addition, rooms and halls for residents on EBP lacked red biohazard or designated bins for disposing of used PPE, leaving only regular trash cans available.
The facility did not submit the required five-day follow-up investigation results to the State Agency within the mandated timeframe for a resident involved in an incident of suspected abuse, neglect, or theft. The DON confirmed the report was submitted late, and the Administrator acknowledged the expectation for timely submission.
A resident returned from the hospital with a fractured scapula and required orthopedic follow-up, but the facility did not initiate a timely investigation, document findings, or report the injury of unknown origin to the State Agency as required. Both the DON and Administrator were unaware of the injury, resulting in a failure to comply with internal policy and state reporting requirements.
A resident with severe cognitive impairment and a diagnosis of unspecified dementia with agitation received Risperdal 1 mg daily over several months without documented informed consent, despite facility policy requiring consent for psychotropic medications used to manage behavioral symptoms. Physician orders and MARs showed continuous Risperdal administration for delusions, mood changes, and dementia-related agitation, while the record contained consent forms only for other antipsychotics (Quetiapine and Seroquel). The DON reported that staff are expected to obtain resident or family consent for psychotropic medications within 24 hours and acknowledged that no consent form for Risperdal was present for this resident, contrary to facility policy.
A resident with documented blindness in one eye and an acquired absence of the eye was incorrectly coded as having adequate vision on a Quarterly MDS assessment. The resident’s care plan identified blindness-related fall risk and interventions to address impaired vision, and physician orders documented evaluation and referral for loss of vision. During interview, the MDSC confirmed the assessment was inaccurate and acknowledged the resident is legally blind and does not have adequate vision.
The facility failed to create complete and timely baseline care plans for two newly admitted residents. For one resident with multiple complex diagnoses, including hepatic encephalopathy, dysphagia, alcoholic cirrhosis, pneumonia, thrombocytopenia, COPD, limb contractures, seizures, and a history of suicidal behavior, the baseline care plan omitted several of these conditions. For another resident with psychiatric disorders, suicidal ideation, insomnia, anxiety, pain, generalized muscle weakness, gait abnormalities, and cognitive communication deficit, no baseline care plan was developed within the required 48 hours after admission; it was completed ten days later. The DON confirmed that all relevant diagnoses should be included on admission and that baseline care plans are expected within 48 hours.
Two cognitively impaired, fully dependent residents were found lying in their beds with an open window in their room while the outside temperature was 32°F, and one bed was directly beneath the open window. Both stated they were freezing and wanted the window closed but lacked the physical ability to get up or close it. A CNA reported she had opened the window to air out the room without asking permission, was unaware of the freezing temperature, and left the room despite knowing the residents could not close the window. An LPN confirmed the residents were not strong enough to close the window, while the DON and Administrator later described expectations that windows remain closed unless specifically requested and after appropriate education about outside temperatures.
A resident with ESRD and dependence on hemodialysis had care plan directives for monitoring dialysis labs and an external hemodialysis catheter, with standing orders for dialysis three times weekly. Facility policy required ongoing pre- and post-dialysis assessments and use of a dialysis communication sheet for every treatment. However, review of the EHR over several months showed only three dialysis communication forms, and Medical Records confirmed no additional documents were missing. The DON stated that the dialysis communication sheet is expected to accompany the resident to and from every dialysis visit to provide current clinical information and updates, but acknowledged that communication for this resident was not consistent.
A resident with ESRD, dysphagia, and dependence on renal dialysis had physician orders and a care plan for a renal diet with Dysphagia Advanced texture and thin liquids, with monitoring for aspiration. Despite this, the Dietary Manager reported that all dialysis residents were routinely sent with sack lunches containing items such as turkey or peanut butter sandwiches, graham crackers, and applesauce, and the resident stated he could not safely eat the sandwich due to choking concerns. The DON confirmed the ordered renal/dysphagia diet and dysphagia diagnosis but was unaware of the specific sack lunch contents, acknowledging that a turkey sandwich would not be appropriate for this diet. Dietary staff and nursing leadership lacked oversight of the dialysis sack lunches, resulting in food items that did not comply with the resident’s ordered therapeutic diet.
The facility failed to maintain accurate medical records by allowing multiple residents’ weight entries to reflect implausible, unverified gains over short periods, which the DON later acknowledged appeared to be documentation errors and contrary to her expectations for accurate nursing documentation. In addition, a resident’s discharge records were inconsistent: although the resident was transferred to a hospital for wound follow‑up after a change in condition, the MDS showed a discharge to home/community and a physician discharge summary note was entered more than two months after the actual transfer date, with the DON and Administrator confirming the documentation did not accurately reflect the resident’s actual discharge disposition.
Surveyors found that the facility did not maintain a functioning call light system in multiple occupied and unoccupied rooms, including bathrooms and bathing areas, despite a policy requiring working call lights or alternative communication devices at each bedside, toilet, and bathing room. Observations showed that call lights in several rooms did not activate when pressed, and a resident was seen attempting to use a nonfunctioning call light. The Maintenance Director acknowledged that these call lights should have been operational and that they should have been replaced sooner, while a CNA was observed replacing a broken call light with a working one.
The facility sent involuntary discharge notices containing personal health information for two residents to the State LTC Ombudsman in the wrong state, rather than to the appropriate New Mexico ombudsman. This occurred after the Social Services Director used a template with incorrect contact details provided by corporate leadership, resulting in unauthorized disclosure of resident information.
A resident with dementia and dysphagia was found unable to speak and with sandwich crumbs around their chair, prompting an investigation into possible neglect. Although the investigation was completed within five days, the facility did not submit the required Five Day Follow-Up Report to the State Survey Agency as outlined in facility policy.
The facility did not send involuntary discharge notices for two residents to the correct State LTC Ombudsman, instead sending them to an Ombudsman in another state. The Social Services Director followed a template with incorrect contact information, and the New Mexico Ombudsman confirmed she did not receive the required notifications.
The facility failed to ensure informed consent for medications for two residents. One resident was prescribed quetiapine without a consent form or behavior monitoring, while another received buspirone and risperdal without signed consent from the resident or their POA. The DON confirmed the oversight, which was only addressed during a later facility-wide review.
The facility failed to maintain a homelike environment for residents due to unresolved maintenance issues, including a damaged shower bed mattress, broken curtain rods, and a malfunctioning shower room door. These issues were known to staff and management for months but remained unaddressed, affecting the comfort and safety of residents.
The facility failed to accurately complete MDS assessments for two residents, incorrectly documenting them as not being on dialysis at admission. The MDS Coordinator confirmed the inaccuracies, acknowledging staff coding errors, which could lead to misidentification of clinical complications and inadequate care.
The facility failed to provide complete care plans for two residents, one of whom was on hospice care, which was not included in their care plan. Another resident's care plans for delirium, oral health, and psychotropic drug use were incomplete, lacking time frames and reasons for delirium. The DON acknowledged these deficiencies.
The facility failed to maintain infection control by allowing a damaged shower bed with exposed foam to be used by residents for months. Despite awareness by some staff, the issue was not formally reported or addressed, leading to potential infection risks.
A facility failed to implement pressure ulcer interventions for a resident with a Stage 4 pressure ulcer. Physician orders included a pressure-redistribution cushion and mattress, and instructions to offload the patient every two hours. However, the order to turn the resident every two hours was not included, and a pressure-relieving mattress was not present. The DON confirmed these omissions.
A resident with diabetes, obesity, Guillain-Barre syndrome, and dementia did not receive timely podiatry services despite physician orders. The resident expressed a need for toenail care, but an appointment was delayed until months after admission. The Unit Manager confirmed the resident had not been seen by podiatry, although diabetic residents should be seen monthly.
A resident was observed asleep and slumped forward in her wheelchair, creating a potential accident hazard. Despite two CNAs being present, they did not assist the resident until prompted by a surveyor. The resident agreed to be moved to her bed when asked.
Widespread Environmental Disrepair and Odors Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and functional environment throughout multiple halls, resident rooms, and common areas. Upon initial entrance and during subsequent observations, surveyors noted strong, lingering odors of urine and feces throughout the building, including A-hall and C-hall, and within specific resident rooms. In several rooms, bathroom areas had cracked tiles, black or dirt-like substances around and behind toilets, and dirty or scratched door frames. The main dining room had a broken light fixture with missing plastic covering and tape hanging over a resident dining table, cracked walls and ceilings, dirty ceiling vents including one with black mold-like buildup, and an exit door with scratches and black scuff marks. Across A-hall, C-hall, and D-hall, numerous resident rooms had broken, uneven, or bubbling floor tiles, uneven flooring, and separated baseboard trim with black substances visible behind detached areas. Several rooms had heating/cooling units that were not properly sealed, with visible daylight entering through gaps and associated wall cracks and broken trim. One room had visible yellow expanding foam sealant along the baseboard that was left unfinished and protruding. Multiple rooms had damaged or missing bathroom door trim, puncture holes in bathroom doors with rough, splintered edges, and broken or dirty door frames. Resident furniture in several rooms, including dressers, drawers, and wardrobes, was broken, with loose or missing handles and a wardrobe door off its hinge; one resident chair had torn upholstery. Additional environmental deficiencies included unpainted and uneven patchwork on walls at the entrance to C-hall and near certain rooms, as well as unpainted or unfinished areas throughout the facility. Several fluorescent light fixtures along D-hall were broken and cracked. The Maintenance Director acknowledged awareness of these issues, including broken floor tiles, cracked walls and ceilings related to the building’s foundation, unsealed or deteriorated heating/cooling units, doors and furniture in disrepair, and unfinished foam sealant. He also stated that the facility serves as the residents’ home and that the current environmental conditions did not support a homelike environment.
Inaccurate and Incomplete PASRR Level I Screenings for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of Preadmission Screening and Resident Review (PASRR) Level I screenings for five residents with actual or potential mental illness or related conditions. For one resident with major depressive disorder, PTSD, and unspecified dementia, the PASRR Level I form section asking whether there was a diagnosis or suspected mental illness was left unanswered. The Admission Director later acknowledged that major depressive disorder is a mental illness and that the admission department was responsible for completing the PASRR, confirming the screening was incorrect because the key mental illness question was not answered. Another resident with a diagnosis of major depressive disorder had a PASRR Level I in which Section C, the mental illness identification section listing mood and other psychiatric disorders, was left unanswered. This same resident’s baseline care plan documented use of an antidepressant for depression, and physician orders included monitoring for increased depression or suicidal ideation, tele-psychiatry services, and sertraline for depression. A PHQ-2 to 9 depression screening documented the resident feeling down, depressed, or hopeless, but the tool was incomplete and lacked a score. The Admission Director stated that major depressive disorder is a mental illness and that the PASRR was incorrect because it did not include this diagnosis. For a third resident, the face sheet showed no diagnosis or history of mental illness, yet the PASRR Level I Section C was left unanswered, and the Admission Director stated the screening was incorrect because the mental illness evaluation question was not answered. A fourth resident had documented diagnoses of major depressive disorder and anxiety disorder, but the PASRR Level I Section C was marked as "not identified" for mental illness, despite the baseline care plan and physician orders reflecting antidepressant use and monitoring for depression; the Admission Director believed the PASRR was correct and was unaware of the major depressive disorder diagnosis. A fifth resident had a diagnosis of anxiety disorder, and the MDS coded anxiety disorder as an active diagnosis, but the PASRR Level I Section C was marked as "not identified" for mental illness, and the Admission Director again believed the PASRR was correct and was unaware of the resident’s anxiety and major depressive disorder diagnoses. These findings show multiple instances where PASRR screenings were incomplete or inaccurately reflected residents’ mental health diagnoses.
Failure to Revise Care Plan After Resident Returned With Fracture and New Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive, person-centered care plan after a documented change in condition following a hospital stay. The facility’s Person-Centered Care Plan Policy, revised 09/15/25, requires that the care plan be revised after each assessment and upon changes in the resident’s condition, and that the IDT review and revise the care plan to ensure safe and appropriate delivery of care. Record review showed that the resident was discharged from the hospital with a confirmed right scapular spine fracture with nonunion, was to return wearing a sling, receive orthopedic follow-up on 11/26/25, and be monitored for pain and mobility changes. Despite these hospital discharge instructions, review of the resident’s care plan dated 12/02/25 revealed no revision to include the diagnosed fracture, no interventions for immobilization, no instructions for staff regarding assistance with transfers or mobility, and no pain-specific interventions related to the fracture. A CNA reported that the resident was supposed to use a sling but did not consistently wear it and continued to push himself up with the injured arm, and stated she had not been given any care plan direction or training about sling use or mobility precautions. The Administrator stated the care plan should be revised when a resident returns from the hospital with new diagnoses and treatment requirements, acknowledged he was unaware of the fracture, and indicated the DON was responsible for ensuring care plan updates. The Medical Director stated he was aware of the broken scapula and expected the facility to follow the hospital’s recommendations and care plan all interventions.
Failure to Monitor Medication Fridge Temperatures and Date Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to ensure drugs and biologicals were stored and monitored according to professional standards, specifically related to medication refrigerator temperature logs and insulin pen dating. During observation of the locked medication room, the refrigerator temperature log forms for the months of September through November 2025 were found to be incomplete, indicating that temperatures were not being routinely monitored as required. This was confirmed in an interview with the DON, who stated that nurses are expected to complete the fridge temperature log once each shift, and acknowledged that this did not occur. In addition, during observation of a nurse medication cart, insulin pens assigned to multiple residents were found without dates indicating when they were first used and without discard dates 28 days after first use. In an interview, an RN confirmed that the insulin pens were not dated when first used and were not dated for discard after 28 days, and stated that undated insulin pens are considered expired and should be disposed of appropriately. The DON also confirmed that undated insulin pens are considered expired and should not be present in the medication carts.
Failure to Follow Hand Hygiene, Catheter Care, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, beginning with improper hand hygiene during medication administration. During a morning medication pass, a certified medication aide administered a resident’s medications and then immediately returned to the medication cart to document and prepare the next resident’s medications without performing hand hygiene. In an interview, the aide acknowledged she forgot to perform hand hygiene and confirmed that facility infection control policy requires hand hygiene after each medication administration. The facility also failed to maintain proper catheter tubing management for two residents with indwelling urinary catheters. One resident with a history of malignant neoplasm of the kidney, benign prostatic hyperplasia, and severe cognitive impairment (BIMS score of 6) had an active order for an indwelling Foley catheter for chronic urinary retention or incontinence with discomfort. On multiple observations in the dining room and hallway, this resident’s catheter tubing was seen dragging across the floor as he propelled himself in his wheelchair. Staff interviews, including with an LPN, the DON, and the Administrator, confirmed that catheter tubing should not drag on the floor because it could cause infection or be pulled out, and that their expectation was that tubing be properly secured below the bladder and off the ground. A second resident with dementia, history of traumatic brain injury, adult failure to thrive, and severe cognitive impairment (BIMS score of 2) was observed seated in a wheelchair with the drainage bag in a privacy bag off the floor, but the catheter tubing between the resident and the bag was routed under the wheelchair and dragging on the floor. Staff again confirmed this should not occur and reiterated expectations that catheter tubing be secured and not touch the ground. The facility further failed to implement Enhanced Barrier Precautions (EBP) and appropriate PPE disposal for residents with indwelling devices and wounds. The facility’s EBP policy required gown and glove use during high-contact resident care activities for residents with wounds or indwelling devices, posting of EBP signage, and use of appropriate receptacles for contaminated PPE. One resident on EBP had signage posted on the room door, but there was no red biohazard or designated bin in the room, only a single trash can shared by both roommates. During care, the ADON and a medical records staff member transferred this resident from wheelchair to bed without using PPE, and the ADON later stated she was unsure of the EBP policy, whether she should have been following EBP during that care, and how PPE should be disposed of. Another resident with a surgical wound, Foley catheter, and care plan specifying EBP (including gown and glove use for high-contact activities and changing PPE before caring for another resident) had EBP signage posted, but repeated observations showed no biohazard bin in the room or on the hall, despite reusable gowns being available. On multiple occasions, RNs provided care to this resident without wearing PPE, and in interviews they acknowledged the resident was on EBP, that they were not using proper PPE, that there were no biohazard bins in the room, and that their expectation was for staff to follow EBP and have appropriate bins available for PPE disposal. Across these observations, the facility did not ensure staff consistently followed its own infection control policies for hand hygiene, catheter care, and EBP implementation. Staff at various levels, including direct care staff and nursing leadership, either did not follow or were uncertain about EBP requirements, and rooms designated for EBP lacked appropriate biohazard or designated bins for contaminated PPE disposal. These actions and inactions resulted in the cited infection prevention and control deficiency for the residents reviewed.
Late Submission of Five-Day Follow-Up Investigation Report
Penalty
Summary
The facility failed to submit the required five-day follow-up investigation results to the State Agency for one resident involved in an incident of suspected abuse, neglect, or theft. According to the facility's Abuse Prohibition policy, the Administrator or designee is responsible for reporting findings of all completed investigations within five working days using the state online reporting system. Record review and staff interviews confirmed that the five-day follow-up report for the incident was submitted late, as acknowledged by the DON, who provided the date and time of the delayed submission. The Administrator also confirmed the expectation that all five-day follow-up reports be submitted within the required timeframe.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation and timely reporting of an injury of unknown origin for one resident. According to the facility's Abuse Prohibition policy, any injury or suspected neglect must be investigated within twenty-four hours, documented, and reported to the State Agency, with a completed investigation summary submitted within five days. In this case, a resident was discharged to the hospital due to uncontrolled pain and was later diagnosed with a right scapula fracture. Upon return to the facility, the resident required orthopedic follow-up and had his right arm immobilized in a sling. Despite receiving notification from the hospital regarding the fracture, there was no evidence that the facility initiated an investigation within the required timeframe, submitted a report to the State, or completed the mandated five-day follow-up. Interviews with the DON and Administrator revealed that neither was aware of the fracture diagnosis when the resident returned, and both acknowledged that the injury should have been investigated and reported as required by policy. The deficiency centers on the facility's failure to respond appropriately to an injury of unknown origin by not initiating, documenting, or reporting the incident as mandated.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or their representative was informed about and consented to the use of a psychotropic medication, specifically Risperdal. The facility’s “Behaviors: Management of Symptoms” policy, revised on 09/15/25, required that residents exhibiting behavioral symptoms be individually evaluated and that consent be obtained from the resident or representative when medication is ordered for behavioral symptoms. One resident, originally admitted with a diagnosis of unspecified dementia with agitation, had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Nursing progress notes showed that on 08/04/25, the primary care physician determined a gradual dose reduction was contraindicated due to ongoing behaviors and ordered Risperdal 1 mg. Physician orders documented multiple Risperdal 1 mg orders beginning in early August 2025 for delusions, mood changes, and severe unspecified dementia with agitation, with the final order remaining active. The medication administration records for September, October, and November 2025 showed that Risperdal was administered daily during those months. Review of psychotropic medication consent forms revealed consents for Quetiapine and Seroquel on several dates, but no consent form for Risperdal. During an interview, the DON stated that when a psychotropic medication is determined to be needed, staff are to obtain consent within 24 hours, either by resident signature or verbal consent from family, and that all nurses are responsible for obtaining consent forms. The DON confirmed that there was no consent form for Risperdal for this resident and that there should have been one.
Inaccurate MDS Vision Assessment for Legally Blind Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident. Record review showed that this resident was admitted with diagnoses including blindness in one eye and acquired absence of the eye. Despite this, the resident’s Quarterly MDS, Section B (Hearing, Speech and Vision), dated 10/27/25, was coded as the resident having adequate vision. This coding conflicted with the resident’s documented medical history and diagnoses. Additional records reinforced that the resident had significant visual impairment. The care plan dated 10/15/25 identified the resident as being at risk for falls related to blindness in one eye and included interventions to arrange the environment to enhance vision, reposition items within the visual field, and monitor vision impairment as a factor in ADL decline. Physician orders dated 12/05/25 documented a referral to ophthalmology for loss of vision to the left eye and transfer to the emergency department for evaluation of blindness in that eye. During an interview, the MDS Coordinator acknowledged that the 10/27/25 MDS assessment was inaccurate and stated that the resident is legally blind and does not have adequate vision, and that it is her expectation that every MDS be completed with correct medical history and diagnoses.
Failure to Develop Timely and Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement adequate baseline care plans within 48 hours of admission for two residents. For one resident admitted with multiple complex diagnoses, including hepatic encephalopathy, dysphagia, GERD, alcoholic cirrhosis, dementia with behavioral disturbance, pneumonia, secondary thrombocytopenia, vitamin D deficiency, sequelae of cerebral infarction, COPD, multiple limb contractures, cognitive communication deficit, epileptic seizures, and a history of suicidal behavior, the baseline care plan dated on the admission day did not address several of these conditions. Specifically, dysphagia, alcoholic cirrhosis of the liver, pneumonia, secondary thrombocytopenia, COPD, muscle contractures in all four limbs, epileptic seizures, and history of suicidal behavior were omitted from the baseline care plan. During interview, the DON confirmed these diagnoses should have been included and stated that the admitting nurse is responsible for reviewing all admission documents and including all relevant diagnoses in the baseline care plan. For another resident, the facility did not develop any baseline care plan within 48 hours of admission. This resident’s face sheet listed major depressive disorder with psychotic features, brief psychotic disorder, suicidal ideations, insomnia, anxiety disorder, pain, generalized muscle weakness, lack of coordination, abnormalities of gait and mobility, and cognitive communication deficit. However, the baseline care plan for this resident was not created until ten days after admission, outside the required 48-hour timeframe. In interview, the DON confirmed the admission and care plan dates and stated that her expectation is that care plans are created within 48 hours.
Failure to Maintain Safe Room Temperature and Supervision When Window Left Open in Freezing Weather
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe room temperature and provide adequate supervision to prevent accidents for two residents who were cognitively impaired and physically dependent for mobility. One resident had unspecified dementia with a BIMS score of 01, was dependent for lying to sitting, sit to stand, and bed-to-chair transfers, and did not ambulate due to medical/safety concerns. The other resident had a diagnosis of lack of coordination, a BIMS score of 05 indicating severe cognitive impairment, was dependent for bed mobility and transfers, and also did not ambulate due to medical/safety concerns. Both residents lacked the physical ability to get out of bed or close a window independently. Surveyors observed both residents lying in their beds while the room window was open, with the curtain blowing inward, when the outside temperature was 32°F. One resident’s bed was directly beneath the open window, and both residents stated they wanted the window closed because they were freezing. A CNA reported that she had opened the window approximately five minutes earlier to air out the room, did not request permission from either resident, did not realize the outside temperature was 32°F, and left the room after opening the window, despite acknowledging that neither resident was strong enough to close it. An LPN confirmed that neither resident was physically strong enough to close the window. The DON stated her expectation that windows remain closed unless requested by the resident after being educated on the outside temperature, and the Administrator stated his expectation that all windows in resident rooms stay closed at all times.
Inconsistent Dialysis Communication and Monitoring for Hemodialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure ongoing communication and coordination with a dialysis provider for a resident receiving hemodialysis. The facility’s Dialysis Policy dated 08/07/23 required nursing staff to complete ongoing assessments and monitoring before and after dialysis treatments. The resident’s face sheet documented end stage renal disease and dependence on renal dialysis, and the care plan dated 04/22/23 included monitoring dialysis labs and the external hemodialysis catheter. The resident’s orders dated 12/05/25 specified dialysis on Monday, Wednesday, and Friday. Record review of the resident’s EHR Hemodialysis Communication forms from 06/01/25 through 12/06/25 showed only three dialysis communication forms for that entire period (08/20/25, 08/25/25, and 09/15/25), with no additional forms present. Medical Records staff stated that all dialysis communication notes had been uploaded and there was no outstanding documentation not scanned into the record. The DON reported that the facility uses a dialysis communication sheet that must accompany each resident to and from every dialysis appointment to provide current clinical information and updates on any changes, and acknowledged that dialysis communication for this resident was not consistent. The DON stated her expectation is that there is communication between the facility and the dialysis provider for every appointment.
Failure to Provide Dialysis Sack Lunch Consistent With Ordered Renal/Dysphagia Diet
Penalty
Summary
The facility failed to provide a diet in accordance with physician orders for a resident with end stage renal disease, dysphagia, and dependence on renal dialysis. The resident’s care plan, dated 04/22/23, directed provision of a Dysphagia Advanced diet with thin liquids, monitoring for signs and symptoms of aspiration, and withholding food and liquids if coughing occurred. A physician order dated 12/18/24 specified a renal diet with dysphagia advanced texture and standard thin liquids. Despite these orders, the resident reported that on days he left the facility for dialysis, he was sent with a sack lunch containing a sandwich that he could not eat because he could choke. The Dietary Manager stated that all dialysis residents are sent with a sack lunch and that this resident received a turkey or peanut butter sandwich, graham crackers, and applesauce. She stated it was her responsibility to review residents’ diet orders and that her expectation was for all diet orders to be followed. The DON confirmed the resident’s renal/dysphagia advanced diet and dysphagia diagnosis, and acknowledged the resident was sent to dialysis three times weekly. The DON was unaware of the specific contents of the sack lunches and stated that while a resident on a dysphagia/renal diet could eat a peanut butter sandwich, a turkey sandwich would not be appropriate due to sodium content and potential for choking. Dietary staff and nursing leadership lacked awareness of and oversight over the dialysis sack lunch contents, resulting in food items inconsistent with the ordered renal/dysphagia advanced diet being provided.
Inaccurate Weight Documentation and Discharge Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent medical records, specifically related to weight documentation and discharge records. For several residents, weight tracking showed implausible or inconsistent values that facility staff, including the DON, later characterized as documentation errors. One resident’s weight record reflected a gain of over 50 pounds within a one‑month period, and another resident’s record showed a large weight gain over a short period that the DON acknowledged appeared to be inaccurate. The DON stated it was her responsibility to ensure nurses accurately document resident weights and that her expectation was that staff correctly document resident weights. The facility also failed to maintain accurate discharge documentation for another resident. This resident was admitted in late August and transferred out of the facility to the hospital in early September for a wound follow‑up, as reflected in a physician order and the DON’s interview. However, the resident’s MDS indicated a discharge to home/community rather than to the hospital, and a physician discharge summary note was entered in the progress notes more than two months after the actual transfer date. The DON stated she did not know why the discharge summary note was entered on the later date or why the MDS showed a discharge to home/community, and she indicated that nurses were responsible for accurate assessments and the MDS coordinator was responsible for MDS accuracy. The Administrator confirmed the resident had been scheduled for discharge home but was instead sent to the hospital after a change in condition, and that the MDS should have reflected a discharge to the hospital.
Failure to Maintain Functioning Call Light System in Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system in resident bathrooms and bathing areas, as required by its own Call Lights policy. The policy, last revised on the cited date, states that residents will have a call light or alternative communication device at each bedside, toilet, and bathing room, and that staff will immediately report call light problems to the supervisor and/or Maintenance Director and provide immediate or alternative solutions until repairs are made. Surveyor observation on the cited date at 1:20 p.m. showed that the call lights above an occupied resident room (29A) and unoccupied rooms (27A, 26A, and 25A) did not turn on when the call buttons were pressed. In a separate observation at 1:10 p.m. in room [ROOM NUMBER]B, a resident was seen attempting to use her call light. During an interview at 12:20 p.m., the Maintenance Director stated that the call lights for rooms 29A, 27A, 26A, and 25A should have been working and acknowledged that residents need functioning call lights in case they need assistance. The Maintenance Director also stated that nurses may directly notify maintenance of needed repairs and that maintenance would repair them right away. Later, at 1:37 p.m., a CNA was observed in room [ROOM NUMBER]B switching out a broken call light with a working one. In a further interview at 12:20 p.m., the Maintenance Director confirmed that the call light in room [ROOM NUMBER]B should have worked but did not, and acknowledged that it should have been replaced sooner but was not.
Failure to Safeguard Resident Health Information During Discharge Notification
Penalty
Summary
The facility failed to safeguard residents' personal health information by sending involuntary discharge notices for two residents to the State Long-Term Care Ombudsman in another state, rather than to the appropriate ombudsman in New Mexico. Record reviews confirmed that the discharge notices for both residents were mailed to the wrong state, and not to the New Mexico State Ombudsman as required. This resulted in the residents' personal and medical information being shared with an unauthorized entity. During interviews, the New Mexico State Ombudsman reported learning of the error when contacted by the ombudsman from the other state, who had received the discharge notices. The State Ombudsman expressed concerns about the improper disclosure of resident information and the lack of resolution to ensure future notices would be sent correctly. The Social Services Director acknowledged sending the notices to the wrong state, explaining that she used a template provided by her Corporate Social Services Director, which included incorrect ombudsman contact information. She was unaware that the notices were sent to the incorrect recipient.
Failure to Submit Required Five Day Follow-Up Report for Alleged Neglect
Penalty
Summary
The facility failed to complete and submit a Five Day Follow-Up Report to the State Survey Agency regarding an allegation of neglect involving a resident. According to the facility's policy, all reportable incidents and conditions must be investigated, documented, and reported to the appropriate State Agencies within five working days. In this case, a resident with dementia and dysphagia was observed by a nurse to be unable to speak, with a flushed face and watery eyes, and crumbs from a sandwich were found around the resident's chair. This incident was documented as a Facility Reported Incident. Although the investigation into the incident was completed within the required five-day period, there was no documentation showing that the Five Day Follow-Up Report was submitted to the State Survey Agency as required by policy. The DON confirmed during an interview that while the investigation was completed on time, the necessary follow-up report was not sent to the State Agency.
Failure to Notify Correct State Ombudsman of Involuntary Discharge
Penalty
Summary
The facility failed to provide a copy of the planned Involuntary Discharge Notice to the correct State Long-Term Care Ombudsman for two of three residents reviewed. For both residents, record review showed that the Involuntary Discharge Notices were sent to the Ombudsman in another state rather than to the New Mexico Long-Term Care Ombudsman. Interviews with the New Mexico Ombudsman confirmed that she did not receive the discharge notices for either resident. The Social Services Director (SSD) stated during interviews that she sent the notices to the wrong state’s Ombudsman, following instructions from the Corporate SSD and using a template that included incorrect contact information. As a result, the required notifications were not provided to the appropriate state entity, as confirmed by both documentation and staff interviews.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents or their guardians were fully informed and understood the reasons for taking certain medications, as well as the associated risks and benefits. This deficiency was identified for two residents, R #19 and R #66, who were reviewed for unnecessary medications. For R #19, the physician's orders included quetiapine fumarate for agitation, but the medical record lacked a consent form for this medication. Additionally, the Director of Nursing confirmed that there was no monitoring of R #19's behaviors while on the medication from the start date through early July. For R #66, the resident's diagnoses included dementia and drug-induced subacute dyskinesia. The resident was prescribed buspirone for anxiety and risperdal for dementia-related behaviors. However, the medical records did not contain a signed consent form by the resident or their Power of Attorney for the administration of these psychotropic medications. The Director of Nursing acknowledged that the consent should have been obtained shortly after the resident's admission, but it was not completed until a facility-wide review was conducted months later.
Facility Fails to Maintain Homelike Environment Due to Unresolved Maintenance Issues
Penalty
Summary
The facility failed to provide a homelike environment for four residents due to several maintenance issues. A resident reported that the shower bed she used had a large hole, causing discomfort during use. This issue was known to the staff, including CNAs and management, for months, yet no action was taken to replace the damaged mattress. During an observation, the shower bed was found to have multiple cracks and a large hole exposing the pipe frame. The Administrator, when interviewed, stated he was unaware of the condition of the shower bed, although it was acknowledged that the bed should not be used in its current state. Additionally, the facility had issues with curtain rods in multiple resident rooms, where curtains were falling off and could not be closed due to missing clips. The housekeeping staff had reported these issues several times, but they remained unresolved. The Administrator was aware of the curtain issues and had purchased extra clips but was unsure about the maintenance requests. Furthermore, the shower room door was broken, with a large chunk missing around the handle area, preventing it from locking. The Administrator and Maintenance Director were aware of the door's condition, which had been problematic for months, but the replacement process was delayed due to reliance on outside companies.
Inaccurate MDS Assessments for Dialysis Status
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. Upon review, it was found that both residents were inaccurately documented as not being on dialysis at the time of their admission assessments. Specifically, the admission MDS Assessment for one resident, dated 05/21/24, incorrectly indicated that the resident was not on dialysis, despite the resident being on dialysis at admission. Similarly, another resident's admission MDS Assessment, dated 07/16/24, also inaccurately reflected that the resident was not on dialysis, although the resident was receiving dialysis treatment at the time of admission. During an interview on 07/22/24, the MDS Coordinator confirmed the inaccuracies in the MDS Assessments for both residents, acknowledging that the staff had incorrectly coded the assessments. This failure to accurately complete the MDS assessments could lead to misidentification of clinical complications and inadequate care for the residents' medical conditions.
Incomplete Care Plans for Hospice and Delirium
Penalty
Summary
The facility failed to ensure comprehensive care plans for two residents, leading to deficiencies in their care. For one resident, the care plan did not include hospice care, despite the resident being on hospice since April. The Director of Nursing (DON) acknowledged that hospice care should have been included in the care plan on the day it was ordered, but it was not addressed until July. For another resident, the care plans for delirium, oral health, and psychotropic drug use were incomplete. The care plans lacked specific time frames for achieving goals and did not provide reasons for the resident's delirium. The DON confirmed the care plans were incomplete and expressed uncertainty about why they were not fully developed, despite expectations for staff to complete them with measurable time frames.
Inadequate Infection Control Due to Damaged Shower Bed
Penalty
Summary
The facility failed to maintain proper infection prevention measures by not ensuring that the shower bed used by four residents was free of damage. The shower bed had a large hole and several cuts that exposed the foam, which is a porous surface that absorbs water and other substances, making it difficult to clean. This issue was observed during a survey, and it was noted that the foam was exposed in several places, compromising the ability to maintain a sanitary environment. Interviews with residents and staff revealed that the shower bed had been in this condition for months, with residents using it multiple times per week. The Administrator was unaware of the issue, while a CNA confirmed that management staff were aware but had not addressed it. The Maintenance Director stated that the problem was reported verbally rather than through the formal reporting system. This lack of action and communication led to the continued use of the damaged shower bed, posing a risk of infection spread among residents.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to provide pressure ulcer interventions as ordered for Resident #10, who was admitted with a Stage 4 pressure ulcer in the sacral region. The resident's physician orders included the use of a pressure-redistribution cushion for the chair and a mattress for the bed, as well as instructions from the wound clinic to offload the patient every two hours. However, the facility did not include an order to turn the resident every two hours in the physician orders dated 07/24/24, nor was this task included in the Certified Nursing Aides' tasks. During an observation, it was noted that a pressure-relieving mattress was not present on the resident's bed. The Director of Nursing confirmed that the pressure-relieving mattress was not ordered and that the order to turn the resident every two hours was not entered.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide necessary podiatry services for a resident with multiple health conditions, including type 2 diabetes, morbid obesity, Guillain-Barre syndrome, and dementia. The resident, who was admitted in November 2023, expressed a need for toenail care and had requested podiatry services from the nursing staff. Despite a physician's order dated July 1, 2024, for a podiatry referral, and another order on July 23, 2024, for a foot and ankle appointment, the appointment was not scheduled until September 26, 2024. During an interview, the Unit Manager acknowledged that the resident, being diabetic with uncontrolled blood sugars, had not been seen by podiatry and should have been seen monthly since admission. Observations revealed the resident had bandages around her feet and legs, and a brace on one foot, but her toenails were not visible.
Resident Left Unattended in Wheelchair Poses Accident Hazard
Penalty
Summary
The facility failed to ensure a resident was placed in her bed when she was asleep, leading to a potential accident hazard. During an observation, a resident was found asleep and slumped forward in her wheelchair with one arm hanging off the side, indicating she might fall out. This situation was observed twice within a short period, with two CNAs present in the room but not assisting the resident. When questioned, one CNA did not respond to the surveyor's inquiries but eventually asked the resident if she wanted to lie down, to which the resident agreed.
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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