Retirement Ranches Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Clovis, New Mexico.
- Location
- 2221 Dillon, Clovis, New Mexico 88101
- CMS Provider Number
- 325078
- Inspections on file
- 19
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Retirement Ranches Inc. during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and documented preference for showers was placed on transmission-based precautions for COVID-19. After receiving one shower, the resident repeatedly requested additional showers but was told that showers were limited to a specific shower day and that bed baths would be provided during isolation. Over several days, the resident complained of feeling dirty and not being allowed to shower, receiving only partial and complete bed baths until a later date when a shower was finally provided. The DON acknowledged that facility policy is to allow showers upon request even during isolation, and the CNA supervisor stated that if a shower was requested, it should have been provided.
Surveyors found several open bags of frozen food in the facility's walk-in freezer that were not labeled or dated. A dietary aide confirmed the lack of labeling and dating, acknowledging that this did not meet expectations. This issue was identified as likely to affect 83 residents.
The facility did not obtain, document, or communicate residents' wishes regarding code status, medical interventions, or artificial hydration/nutrition. Several residents with complex medical conditions had blank advanced directive sections in their records, and staff confirmed that such information was only collected at admission and not regularly reviewed or updated.
Certified Medical Assistants administered medications to three residents in a commons area in the presence of other residents, staff, and family members, without offering the option for private administration. The DON confirmed that this area is not private and that medications should be given privately.
A resident with multiple mental health diagnoses was prescribed several psychotropic medications without documented consent forms in the medical record. The DON confirmed that staff did not obtain the required consent prior to starting these medications, resulting in the resident and/or their representative not being fully informed about the medications, their risks, or benefits.
Staff provided direct care to multiple residents requiring enhanced barrier precautions (EBP) without using the necessary personal protective equipment (PPE), despite clear signage and facility expectations. PPE carts were not located near resident rooms, and CNAs confirmed in interviews that they did not use PPE while assisting with personal care or vital signs.
A resident with multiple chronic conditions received new physician orders for wound care and foley catheter care, but the care plan was not updated to include these interventions. The DON confirmed the omission during an interview, and the deficiency was identified through record review and staff interview.
A CNA transferred a resident using a mechanical lift without the required assistance from a second staff member, contrary to the resident's care plan. The CNA performed the transfer alone, and this was confirmed through observation, interview, and care plan review, which specified that two staff are needed for such transfers.
The facility did not provide residents with access to their mail on weekends, as confirmed by resident interviews and the Social Services Director, who stated that mail received on Saturdays is not distributed until Monday due to her absence.
A treatment cart near the nurse's station in the 200 hall was observed to be unlocked and unattended, with no staff present in the area. An RN confirmed that the cart should have been locked and secured while not in use, potentially allowing unauthorized access to medical supplies and personal health information for all 34 individuals in that section.
The facility failed to provide and follow menus for all physician-prescribed diets, affecting 80 residents. The Director of Dietary admitted to lacking menus with portion sizes and therapeutic diet plans. Observations showed discrepancies between planned and served meals, with staff making unapproved substitutions. Interviews with staff and residents confirmed inconsistencies in menu adherence, and the Registered Dietitian noted the absence of necessary menu documentation.
A facility failed to secure medication and treatment carts, leaving them unlocked and unattended, contrary to policy. A nurse repeatedly left a medication cart unlocked while attending to residents, with the cart out of view. Observations showed that the carts contained medications and were accessible to staff and potentially residents. Interviews confirmed the expectation that carts should be locked when not in direct view, highlighting a risk of unauthorized access.
Failure to Honor Resident Bathing Preferences During Isolation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choice regarding bathing preferences while on transmission-based precautions for COVID-19. The resident was admitted with multiple diagnoses including type 2 diabetes, a personal history of COVID-19, hypertension, peripheral vascular disease, and chronic pressure ulcers of both heels. The resident’s baseline care plan documented a preference for showers rather than bed baths. The electronic health record showed the resident tested positive for COVID-19 and was placed on isolation precautions. Progress notes indicated the resident received a shower on 01/14/26, then later complained on 01/16/26 about not being able to shower due to being in isolation. The resident again requested a shower on 01/17/26 and was told by staff that the shower day was on Tuesdays. Further record review showed that on 01/19/26 the resident was upset about not being able to shower, stating they felt dirty and needed a shower. On that date, the resident received a partial bed bath in the early morning and a complete bed bath in the afternoon, and did not receive a shower until 01/20/26. The DON stated that residents are informed at the time isolation is initiated that bed baths will be given instead of showers, but also stated that it is policy to allow residents to shower when they ask, even while in isolation, and confirmed that going five days without a shower when a resident is requesting one does not meet her expectations. The CNA supervisor reported not recalling being notified that the resident was upset about not being allowed to shower while in isolation and stated that if the resident requested a shower, the resident should have been showered.
Unlabeled and Undated Food Items Found in Freezer
Penalty
Summary
Surveyors observed that the facility failed to store and serve food under sanitary conditions by not ensuring that food items in the walk-in freezer were properly labeled and dated. Specifically, during an inspection, one open bag each of frozen broccoli, frozen pizza, and frozen bacon were found in the freezer without any labels or dates. During an interview, a dietary aide confirmed that these items were not labeled or dated and acknowledged that this did not meet her expectations, stating that all items in the fridge and freezer should be labeled and dated. This deficiency was identified as likely to affect 83 residents listed on the facility's census at the time of the survey.
Failure to Document and Communicate Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that all residents' wishes regarding emergency and lifesaving care, including code status, medical interventions, and artificial hydration/nutrition, were obtained, documented, and communicated to staff. Record reviews for multiple residents revealed that the Advanced Directives sections of their Face Sheets were left blank, and their electronic health records did not contain documentation of their preferences for medical interventions or artificial hydration/nutrition. These residents had significant medical histories, including chronic kidney disease, acute kidney failure, hypertensive heart disease, aphasia, hemiplegia, hemiparesis, Alzheimer's disease, unspecified convulsions, acute respiratory failure, and myocardial infarction. During an interview, the Admissions Director confirmed that the facility did not have records of residents' wishes regarding full code status, medical interventions, or artificial hydration/nutrition for those without an advance directive. The Admissions Director stated that residents are only asked about advanced directives during admission and that there is no regular review or additional documentation for residents who do not already have an advance directive. The only documentation completed is an emergency medical services DNR form for residents with a DNR status, which does not include information about other medical interventions or artificial hydration/nutrition.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
Staff failed to provide personal privacy for three out of four residents reviewed for privacy during medication administration. Certified Medical Assistants administered medications to these residents in the commons area, which was occupied by other residents, staff, and family members, without offering the residents the option to receive their medications in a private setting. Specifically, medications were given in a public area near the residents' rooms during meal times and other activities, with staff verbally identifying the medications in front of others. The Director of Nursing confirmed that the commons area is not considered private and that medications should be administered privately.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were informed in advance about the medications being administered, including the reasons, risks, and benefits associated with those medications. Record review showed that the resident had multiple diagnoses, including major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, and unspecified mild dementia with mood disturbance. The resident was prescribed several medications, including buspirone, hydroxyzine, Tylenol PM Extra Strength, and venlafaxine, for these conditions. Despite these prescriptions, the medical record did not contain any consent forms for the use of these psychotropic medications. During an interview, the DON confirmed that staff did not obtain the required psychotropic medication consent forms prior to starting these medications, as expected by facility policy. This lack of documented consent meant the resident and/or their representative were not fully informed about the medications being administered.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents requiring this infection control intervention. Personal protective equipment (PPE) carts were observed to be located fifteen to twenty feet away from resident rooms where EBP was required, making immediate access to PPE difficult. Multiple staff members, including certified nurse aides (CNAs), were observed providing direct care to residents with posted EBP requirements without donning the necessary PPE such as gowns, gloves, or masks. In each instance, signage indicating the need for EBP was present at the entrance to the resident's room, but staff entered and provided care without the required protective equipment. Interviews with the involved CNAs confirmed that they assisted residents with personal care or vital signs without utilizing the required PPE, despite being aware of the EBP signage and requirements. The Director of Nursing (DON) also confirmed that staff are expected to use PPE when providing care to residents on EBP. These observations and interviews demonstrate a failure to follow established infection prevention and control protocols for residents identified as needing enhanced barrier precautions.
Care Plan Not Updated for New Wound and Catheter Care Orders
Penalty
Summary
The facility failed to update a resident's care plan to reflect new diagnoses and treatment interventions. Specifically, a resident admitted with multiple complex conditions, including Type II Diabetes Mellitus, chronic heart failure, hypertensive heart disease, a traumatic amputation, and benign prostatic hyperplasia, received new physician orders for wound care and foley catheter care. However, a review of the resident's care plan showed that it had not been revised to include these new interventions. During an interview, the DON confirmed that the care plan was not updated to address the wound care and catheter care needs, acknowledging that this did not meet expectations. The lack of updates to the care plan was identified through record review and staff interview, and no information about the new wound or catheter care interventions was present in the care plan at the time of review.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A Certified Nursing Assistant (CNA) transferred a resident using a mechanical lift without the required two-person assistance, as specified in the resident's care plan. During a random observation, the CNA was seen entering the resident's room alone with a mechanical lift and remained inside for approximately 15 minutes before exiting. The CNA later confirmed in an interview that she performed the transfer by herself, believing that the lift could be operated by one person. Review of the resident's care plan indicated that transfers with the maxi lift require assistance from two staff members. The Certified Nursing Assistant Coordinator also confirmed that the care plan mandates two-person assistance for transfers for this resident.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that all 83 residents had reasonable access to and privacy in their use of communication methods, specifically regarding the timely delivery of mail on Saturdays. During a Resident's Council Meeting, residents reported that mail was not delivered on Saturdays, and one resident stated he had never received mail on a Saturday, even when expecting a package. The Social Services Director confirmed that mail is not delivered to residents over the weekend because she does not work on Saturdays, resulting in any mail received during that time being held until Monday.
Unattended Unlocked Treatment Cart
Penalty
Summary
A treatment cart located near the nurse's station in the 200 hall was found unlocked and unattended during a random observation. At the time of the observation, no facility employees were present in the area. This situation was confirmed by a registered nurse, who acknowledged that the treatment cart should have been locked and secured while not in use. The unlocked cart had the potential to allow unauthorized access to medical supplies and personal health information for all 34 people residing in the affected side of the facility.
Failure to Follow and Provide Menus for Prescribed Diets
Penalty
Summary
The facility failed to ensure that menus were in place for all physician-prescribed diets and did not follow the menu for all 80 residents. The facility's policy required menus for regular and therapeutic diets to be written and posted in advance, reviewed by a dietitian, and include portion sizes. However, the Director of Dietary (DOD) admitted that the only menu available lacked portion sizes and did not cater to therapeutic or texture-modified diets. During meal observations, it was noted that the menu items served did not match the planned menu, and substitutions were made without proper documentation or approval. The DOD and the cook made decisions on portion sizes and substitutions without consulting the dietitian or having a structured plan. Interviews with staff and residents revealed inconsistencies in menu adherence and a lack of available alternatives when menu items were missing. The Registered Dietitian (RD) confirmed that there should have been a binder with detailed menus and portion sizes for different diets, which was not available. The Director of Nursing (DON) acknowledged that the menu should have been followed and that missing items could have been procured. Resident interviews and council meeting minutes further highlighted the issue of menus not being consistently followed, with residents often receiving repetitive meals. The facility had a variety of diet orders, but there was no planned menu to accommodate these specific dietary needs.
Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication and treatment carts were securely locked when unattended, as observed during a survey. Specifically, one out of six medication carts and one out of two treatment carts were found unlocked and unattended on multiple occasions. The facility's policy requires that medication carts be locked when not in use or out of the nurse's view to prevent unauthorized access. However, observations revealed that a Registered Nurse (RN1) repeatedly left the medication cart unlocked while attending to residents in their rooms, with the cart out of her view. During the survey, it was noted that RN1 left the medication cart unlocked on several occasions while she was inside residents' rooms with the doors closed, making the cart not visible to her. This occurred on different halls within the facility, including the 100, 200, and 300 halls. The surveyor was able to open the drawers of the unattended carts, confirming the presence of medications inside. Additionally, other staff members, including Certified Nursing Assistants (CNAs), were observed walking by the unlocked carts, further highlighting the risk of unauthorized access. Interviews with RN1 and the Director of Nursing (DON) confirmed the expectation that medication carts should be locked when not in direct view of the nurse. RN1 acknowledged that she should have locked the cart when it was out of her view, especially when moving between different pods within the facility. The DON emphasized the importance of securing the carts to prevent residents, particularly those with dementia, from accessing medications or creams that could be harmful if ingested.
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.
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.
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.
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 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.
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.
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