Rio Rancho Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Rancho, New Mexico.
- Location
- 4210 Sabana Grande Se, Rio Rancho, New Mexico 87124
- CMS Provider Number
- 325033
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Rio Rancho Center during CMS and state inspections, most recent first.
Surveyors found that food and beverages in the north and south nutrition room refrigerators were not consistently labeled, dated, or discarded when expired. Observations showed unlabeled pitchers of beverages, unlabeled pudding cups, and multiple pre-packaged sandwiches, nutritional supplement shakes, and fruit containers stored past their labeled dates. Facility policy required all snacks to be labeled with resident name, current date, and use-by date, and for pantries to be stocked only with covered, labeled, and dated items. The DM reported that Dietary Aides were responsible for checking and removing expired snacks three times daily, and the Administrator stated her expectation that residents not receive expired foods and acknowledged that consuming expired foods could cause illness.
The facility failed to ensure call lights were kept within reach for three residents, resulting in multiple instances where call lights were found on the floor behind or under beds while residents were in bed and needing staff access. A CNA confirmed that call lights are expected to be within reach at all times and acknowledged that the call lights for these residents were not accessible, and the unit manager stated staff are responsible for ensuring call lights remain within residents’ reach.
A resident with failure to thrive died in the facility, and afterward the resident’s daughter discovered multiple unauthorized charges on the resident’s debit card at various retail and food establishments. Bank records showed the transactions began on the day of the resident’s death. The daughter filed a police report and, upon review of video surveillance, it was confirmed that a facility employee used the resident’s debit card without authorization. The ADM acknowledged that the employee’s use of the card after the resident’s death should not have occurred.
A resident with chronic systolic CHF and COPD was repeatedly provided O2 via nasal cannula without any corresponding physician order documented in the EHR. Nursing notes showed multiple instances of O2 administration, and surveyors observed an O2 concentrator with nasal cannula and a portable O2 tank in the room. The resident reported using O2 when experiencing shortness of breath. The UM and Administrator both acknowledged that residents requiring supplemental O2 should have valid physician orders and confirmed that no such order existed for this resident, meaning O2 was administered outside of professional standards of care.
A resident with chronic thrombocytopenia and a femur fracture had a standing order for daily Eltrombopag Olamine 50 mg, including instructions to reorder when only 10 tablets remained, yet the drug was not administered on multiple documented date ranges because it was not in stock or available at the facility. Nursing notes repeatedly cited waiting on delivery or lack of stock, and the resident reported not receiving the medication for several days on multiple occasions. The UM and RN acknowledged that several doses were missed due to the medication not arriving, and the MD stated he was aware of intermittent failures to administer the drug, attributing them to inconsistent ordering processes and delays from a specialty pharmacy, despite facility policy requiring medications to be administered as ordered.
Staff did not consistently use required gowns and gloves during high-contact care activities for a resident with multiple open wounds, despite facility policy mandating enhanced barrier precautions to prevent MDRO transmission. Observations and staff interviews confirmed that PPE use was inconsistent, particularly when residents were agitated or not on isolation precautions.
A resident with a history of brain hemorrhage, hemiplegia, and high fall risk was admitted without a complete baseline care plan addressing essential needs such as fall prevention, ADL assistance, and care interventions. Despite clear risk factors and family concerns, the care plan only included personal interests and omitted critical clinical and safety measures. The resident experienced a fall resulting in ER transfer, and staff interviews confirmed the required care plan was not completed within 48 hours of admission.
The facility failed to honor the preferences of four residents regarding bathing routines and bed positioning. One resident preferred showers but received only bed baths, while another wanted more frequent bathing than provided. A third resident, who preferred bed baths for safety reasons, received fewer than expected. Additionally, a resident's preference to keep his bed in a high position was overridden by a new, undocumented facility practice aimed at fall prevention, causing him distress.
The facility failed to update care plans for several residents, omitting critical information such as hospice care, dialysis, dietary needs, and oxygen use. These omissions could lead to staff being unaware of residents' care needs.
The facility failed to ensure pharmacist recommendations for medication reviews were acknowledged by providers for three residents. Recommendations for medication modifications and monitoring were not documented as reviewed or signed by providers, indicating a lack of follow-through in medication management.
Two residents received medications late, resulting in a 45.45% error rate. One resident received Methacarbamal late, while another received 14 medications late, including those for blood pressure and muscle spasms. The CMAs confirmed the delays, citing staffing issues as a cause.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. Three CNAs did not complete the necessary training hours despite working multiple shifts. The Nurse Educator and DON confirmed the deficiency.
A resident's PHI was compromised when a CMA left a computer screen open and a narcotic book visible, exposing sensitive information to unauthorized individuals. An LPN confirmed the breach, noting that the computer screen and narcotic record should not have been left accessible to unauthorized residents, visitors, and staff.
A resident reported that a night shift CNA was hateful and restricted his use of the call light. The incident was reported to a UM but was not documented or investigated, as the UM, LPN, DON, and ADM were unaware of the allegation. This failure to report and investigate indicates a breakdown in protocol, potentially risking resident safety.
The facility failed to ensure proper discharge planning for two residents, leading to significant deficiencies in their care. One resident was discharged without necessary home health services due to a lack of communication and follow-up, while another was discharged without proper notice or intervention for behavioral issues. These failures resulted in residents being discharged without the support and care they required.
A resident received hospice services without the necessary physician orders. The care plan indicated the start of hospice care, but a review showed no physician orders were present. The DON confirmed the oversight, stating orders should have been obtained before starting hospice care.
A resident with significant impairments following a stroke developed a wound due to inadequate care in a LTC facility. The resident was not repositioned or had her brief changed frequently enough, leading to moisture accumulation and skin breakdown. Family members reported finding her in a soiled brief, and the Wound Care Nurse confirmed the wound resulted from insufficient care.
A resident with a history of repeated falls and an amputated leg was not provided with a fall mat as required by their care plan. Despite having a beveled mattress, the absence of a fall mat was confirmed by the DON, posing a risk of greater injury from falls.
A facility failed to maintain a filled portable oxygen tank for a resident with COPD, who reported the tank leaked and was unusable. Despite notifying staff, no action was taken. A CMA and RN confirmed the tank was empty, acknowledging it should be full and ready for use.
The facility failed to properly store and administer medications, as observed when five loose pills were found in a medication cart and a narcotic was signed out but not administered to a resident. A CMA confirmed the discrepancies, and the DON stated that such practices are considered medication errors.
A resident reported that meals were often cold when delivered to his room. An observation confirmed that the lunch meal temperatures were below the appropriate serving temperature, with the tamale, black beans, and coleslaw measured at 117, 110, and 112 degrees Fahrenheit, respectively. The Dietary Manager and DC acknowledged that these temperatures were not at the correct level.
A resident expressed dissatisfaction with being served cold eggs for breakfast, which they disliked. An observation confirmed the resident was served eggs, which they left uneaten. The resident's meal ticket did not indicate their dislike for eggs, and the Dietary Manager was unaware of this preference.
A facility failed to maintain complete medical records for a resident, as their EMR lacked a required Pre-Admission Screening and Resident Review (PASRR). This omission was confirmed by the DON, highlighting a deficiency in record-keeping that could affect the provision of comprehensive care.
A facility failed to collaborate with hospice services for a resident on hospice care, as no coordinated plan of care was developed. The resident's MDS indicated hospice care, but there was no hospice communication documentation in the medical record. The DON-IT noted the absence of a hospice binder, which should have been available to staff, and the DON confirmed the lack of necessary documentation.
A resident with multiple health conditions, including dementia and respiratory failure, did not receive scheduled showers for a month, with only one documented refusal. The facility's records showed inconsistencies, such as marking showers as 'not applicable' or failing to document them, indicating a breakdown in ensuring necessary care was provided.
A facility failed to ensure the accuracy of the MDS for a resident, leading to discrepancies in documentation regarding the presence of an indwelling catheter. The resident was admitted with a history of urinary issues but was inaccurately recorded as having a catheter in the MDS. Nursing notes indicated the resident requested a catheter, but scans showed no retention. The DON confirmed the MDS was incorrect, as the resident did not have a catheter upon admission.
The facility failed to deliver meals according to the scheduled times, with significant delays observed during lunch service. Two residents experienced late meal deliveries, and one reported receiving an empty plate on occasion. Interviews with the DON and dietary staff confirmed that meal delivery delays were common due to kitchen backups and forgotten trays.
The facility did not have a Registered Nurse (RN) on duty for at least 8 hours each day, as required, due to a shortage of nurses. This issue was identified through a review of staffing schedules from April to July 2024, revealing multiple days without RN coverage. The Scheduling Manager and Administrator were aware of the problem, which potentially affects all 114 residents by risking inadequate service provision.
A facility failed to maintain accurate weights for a resident with multiple diagnoses, including severe protein-calorie malnutrition. The resident was supposed to be weighed weekly for four weeks and then monthly, but only one weight was recorded. Interviews revealed confusion about who was responsible for weighing residents, leading to a deficiency in meeting professional standards of quality.
Improper Labeling, Dating, and Storage of Food and Beverages in Nutrition Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s food and nutrition services related to improper storage, labeling, and dating of food and beverages in the north and south nutrition room refrigerators. The facility’s written policy dated 05/01/23 required food and nutrition employees to prepare, label, and date evening snacks with a use-by date, affix labels including the resident’s name, current date, and use-by date, and ensure pantries were stocked with covered, labeled, and dated items. Despite this policy, observations on 03/09/26 in the south nutrition room revealed one pitcher of a pink-colored beverage and one pitcher of a purple-colored beverage stored in the refrigerator without labels or dates. Additionally, eight pre-packaged peanut butter and jelly sandwiches dated 02/07/26, four pre-packaged turkey sandwiches dated 02/08/26, three Vital Cuisine nutritional supplement shakes dated 03/03/26, and three small pre-packaged containers of strawberries dated 03/05/26 were stored in the refrigerator. Further observations on 03/09/26 in the north nutrition room showed six pre-packaged peanut butter and jelly sandwiches dated 02/07/26, two pre-packaged turkey sandwiches dated 02/08/26, and two Vital Cuisine nutritional supplement shakes dated 03/03/26 stored in the refrigerator, along with three 4-oz pre-packaged containers of chocolate pudding that were not labeled. During an interview on 03/10/26, the Dietary Manager stated that Dietary Aides were responsible for delivering and checking for expired resident snacks in both nutrition rooms three times daily, confirmed that expired food should be discarded, and that all food and beverage items should be labeled and dated. In a separate interview, the Administrator stated her expectation that residents do not receive or consume expired foods and acknowledged that residents could become ill if they consume expired foods.
Failure to Ensure Resident Call Lights Were Kept Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach for three residents. During an observation on 03/10/26 at 10:52 a.m., Resident #25 was seen sitting in bed, appearing uncomfortable and calling out for staff, while his call light was on the floor behind the bed and out of his reach; he confirmed he could not reach it. At 10:54 a.m. the same day, Resident #26 was observed sitting in bed watching television with the call light on the floor under the bed and not accessible. On 03/11/26 at 12:47 p.m., Resident #27 was observed lying in bed with the call light located under the bed and not within reach. Certified Nursing Assistant (CNA) #3 confirmed that call lights should always be within reach of residents and acknowledged that the call lights for Residents #25, #26, and #27 were not within reach as they should have been, further stating that if a call light was not in reach, it could cause a resident to fall. The Unit Manager (UM) #1 stated that staff are responsible for ensuring call lights are within residents’ reach and agreed that the call lights for these three residents were not within reach as required. These observations and staff interviews show that, at the times noted, the facility did not maintain accessible call lights for the three residents, despite staff acknowledging the expectation that call lights be kept within residents’ reach.
Unauthorized Use of Deceased Resident’s Debit Card by Facility Employee
Penalty
Summary
The facility failed to protect a resident’s personal funds from misappropriation when a facility employee used the resident’s debit card without authorization. The resident had been admitted with a diagnosis of failure to thrive and later died in the facility. After the resident’s death and discharge, bank records showed multiple processed transactions on the resident’s debit card, including charges at a restaurant, grocery store, drug store, coffee shop, donut shop, and dry cleaners. These transactions occurred on and after the date of the resident’s death. The resident’s daughter reported that she discovered the unauthorized charges after her mother died and confirmed with the bank that the charges began on the day of death. She filed a police report and stated that the facility was contacted and video footage confirmed a facility employee using the resident’s debit card. The Administrator confirmed that the family reported unauthorized use of the debit card, that an investigation was initiated with local law enforcement, and that police obtained video surveillance showing a facility employee using the resident’s debit card after the resident’s death. The Administrator acknowledged that a facility employee used the resident’s debit card and that this should not have occurred.
Oxygen Administered Without Physician Order
Penalty
Summary
Facility staff administered oxygen to a resident without a physician’s order, failing to ensure services met professional standards of quality. The resident was admitted with chronic systolic congestive heart failure and chronic obstructive pulmonary disease. Nursing progress notes documented that the resident was provided oxygen via nasal cannula on three separate dates (01/11/26, 02/20/26, and 02/23/26). However, review of the electronic health record on 03/09/26 showed there were no past or present physician orders for oxygen use for this resident. During observation of the resident’s room on 03/09/26, surveyors noted an oxygen concentrator with a nasal cannula attached and a portable oxygen tank available for use. In an interview, the resident stated he uses oxygen when he has difficulty breathing. The Unit Manager stated that all residents who need supplemental oxygen should have a physician’s order for PRN or continuous use and confirmed that this resident did not have such an order. The Administrator also stated her expectation that all residents requiring supplemental oxygen have a valid physician’s order and acknowledged that receiving oxygen without an order could result in the wrong treatment and pose a risk to resident safety and health.
Repeated Unavailability of Specialty Medication Leads to Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Eltrombopag Olamine 50 mg PO daily for chronic thrombocytopenia was not administered on multiple occasions due to the medication not being available in the facility. The resident, admitted with a femur fracture and diagnosed with low platelets, had physician orders specifying daily administration of Eltrombopag Olamine and instructions to reorder when only 10 tablets remained. Review of the MAR showed the medication was not administered on multiple date ranges, and nursing progress notes repeatedly documented that the medication was either not in stock, not available in the facility, or that staff were waiting on delivery from the pharmacy. During interviews, the resident reported not receiving the Eltrombopag Olamine for several days and stated this had happened multiple times before. The UM confirmed the resident had missed several doses because the medication had not yet arrived and acknowledged this was not the first time the medication was unavailable. The RN stated it was her expectation that all residents receive medications as ordered and noted that missing this medication could affect platelet function in the event of bleeding. The Medical Director reported being aware of issues with the resident not receiving the medication as ordered, explained that the drug was obtained through a specialty pharmacy with refill delays of a week or more, and attributed the problem to inconsistent ordering practices by different staff, with no single person consistently ensuring timely delivery. The facility’s own Medication Administration Policy required medications to be administered according to prescriber orders and appropriate interventions for medication errors, which did not occur in this case.
Failure to Use Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to utilize enhanced barrier precautions (EBP), specifically the use of gowns and gloves, during high-contact care activities for a resident with multiple open wounds. According to the facility's EBP policy, staff are required to use targeted personal protective equipment during activities such as dressing, bathing, hygiene, and transfers for residents at risk of multidrug-resistant organism (MDRO) transmission. Record review showed that the resident was dependent on staff for all activities of daily living, had multiple pressure ulcers, and required total assistance with hygiene and toileting. During an observed episode of incontinent care and repositioning, staff did not wear a gown and gloves as required by policy. Interviews with staff revealed inconsistent compliance with EBP. An LPN acknowledged that staff often only wore gloves, unless the wound was heavily draining, and did not always use gowns and gloves unless the resident was on isolation precautions. The Director of Nursing confirmed that staff were expected to follow the EBP policy but admitted that compliance was not always consistent, especially when residents became agitated or resisted care. The failure to follow EBP was directly observed and confirmed through staff interviews.
Failure to Develop and Implement Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a resident with complex medical needs and a high risk for falls. Upon admission, the resident had diagnoses including nontraumatic acute subdural hemorrhage, hemiplegia, generalized muscle weakness, and a history of transient ischemic attack. The resident's fall risk assessment indicated a high risk, with contributing factors such as incontinence, impaired gait and balance, recent hospitalization, and predisposing conditions like stroke and arthritis. Despite these findings, the baseline care plan created did not address essential areas such as initial goals based on admission orders, physician and dietary orders, therapy and social services, fall risk, fall prevention interventions, or assistance needs related to activities of daily living, bed mobility, or call light use. The care plan only included the resident's personal interests. Progress notes documented that the resident was lethargic and had ongoing concerns about bleeding risks and supervision needs, as expressed by her son. The resident experienced a non-witnessed fall and was transported to the emergency room, but there was no documentation that the baseline care plan was reviewed or revised following the incident. Further notes indicated the resident was unable to use the call light independently and required staff repositioning, yet these needs were not reflected in the care plan. Interviews with facility staff, including the Unit Manager, Administrator, and DON, confirmed that the expectation was for a complete baseline care plan to be in place within 48 hours, and that the resident's high fall risk should have been addressed in the care plan. However, staff were unaware that a complete plan had not been developed. The resident's son reported that he had communicated his concerns about his mother's fall risk, sedation, and inability to move independently to the nursing staff, and had requested bed rails. He was notified by the facility after his mother fell out of bed and was sent to the emergency room. The resident did not return to the facility after the hospital visit. Staff interviews further confirmed that the resident's high fall risk and need for frequent checks and repositioning were not adequately care planned, and that the required baseline care plan was not completed within the mandated timeframe.
Failure to Honor Resident Preferences in Bathing and Bed Positioning
Penalty
Summary
The facility failed to honor the personal preferences of four residents regarding their bathing routines and bed positioning. Resident #14 expressed a preference for showers over bed baths, yet records showed that he received only bed baths over a three-month period, despite the facility's schedule indicating he should have been offered showers twice a week. Similarly, Resident #59, who preferred more frequent bathing, received only four bed baths since her admission, contrary to the scheduled twice-weekly showers. The Director of Nursing confirmed these discrepancies, acknowledging that the residents' preferences were not being met. Resident #49, who has normal cognitive abilities and a preference for bed baths due to safety concerns with shower transfers, reported receiving only four bed baths over three months. Despite her clear communication of this preference to staff, the facility's records did not reflect additional bathing events. The Assistant Director of Nursing confirmed the limited documentation and acknowledged the resident's ability to express her needs and preferences. Resident #71 preferred to keep his bed in a high position when not in use to prevent other residents from accessing it. However, the facility implemented a practice of lowering beds to prevent falls, which was not documented in the facility's fall management protocol. This practice was applied to Resident #71 without his consent, causing him distress. The Administrator clarified that the intention was to apply this practice to vacant rooms, not occupied ones, and confirmed that the new process was not part of the current fall protocol.
Care Plan Deficiencies for Multiple Residents
Penalty
Summary
The facility failed to update and revise care plans for six residents, leading to deficiencies in their care. For one resident, the care plan did not include hospice care despite a physician's order for hospice services. Another resident did not have a quarterly care plan meeting for over a year, contrary to the requirement for such meetings to occur quarterly. Additionally, a resident receiving dialysis three times a week did not have this service included in their care plan. Further deficiencies were noted in the care plans of other residents. One resident's care plan did not reflect their current diet, as they were being served double portions without an order. Another resident's care plan lacked documentation for diabetic management, insulin use, pain management, and oxygen use, despite having physician orders for these treatments. Lastly, a resident's care plan did not include their oxygen use, which was ordered as needed. These omissions in care planning could result in staff being unaware of the residents' care needs and preferences.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for three out of five residents reviewed. This deficiency was identified through record reviews and interviews, revealing that pharmacist recommendations were not consistently reviewed or acknowledged by the providers. Specifically, the pharmacist's recommendations for medication modifications and considerations for gradual dose reductions (GDR) were not documented as reviewed or signed by the providers, indicating a lack of follow-through on critical medication management processes. For Resident #7, multiple pharmacist recommendations were made over several months, including suggestions for medication modifications and the need for blood sample orders to monitor diabetic therapy. However, there was no evidence that these recommendations were reviewed or acted upon by the provider, as the documents lacked signatures or confirmations of receipt. Similar issues were noted for Resident #27 and Resident #67, where recommendations for GDR and medication renewals were not documented as reviewed by the providers. The Director of Nursing confirmed during an interview that the expectation was for all pharmacist recommendations to be reviewed and signed by the provider, which was not the case for the cited recommendations. This oversight in the medication review process could lead to residents receiving unnecessary or ineffective medications, as the pharmacist's input was not being integrated into the residents' care plans.
Medication Administration Errors Due to Staffing Issues
Penalty
Summary
The facility failed to administer medications to two residents with an error rate less than 5%, resulting in a 45.45% error rate. For one resident, Methacarbamal, prescribed for muscle spasms, was administered at 8:34 am instead of the scheduled 7:00 am, as confirmed by the Certified Medication Aide (CMA) who acknowledged the medication was late. The Medication Administration Record (MAR) corroborated the scheduled time, and the CMA admitted the medication was administered more than one hour past the due time, which is considered late. For another resident, a total of 14 medications, including those for blood pressure, muscle spasms, eye conditions, allergies, urinary tract infection prevention, depression, enlarged prostate, nasal congestion, pain, seizure disorder, gastritis, and constipation, were all administered at 8:55 am instead of the scheduled 7:00 am. The CMA responsible for administering these medications confirmed they were late, stating that medications should be administered no later than one hour past the due time. The CMA also mentioned being the only nurse available to administer medications to her units, leading to frequent delays due to staffing issues.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year, as mandated. This deficiency was identified for three CNAs out of five randomly reviewed. Specifically, CNA #1, hired on June 6, 2022, did not complete the required 12 hours of in-service training for the period from June 6, 2023, through June 6, 2024, despite working sixteen shifts between January 25, 2025, and February 25, 2025. Similarly, CNA #3, hired on October 16, 2020, also failed to complete the required training hours for the period from October 16, 2023, through October 16, 2024, while working sixteen shifts in the same timeframe. CNA #4, hired on August 25, 2017, did not complete the required 12 hours of in-service training for the period from August 25, 2023, through August 25, 2024, and worked fifteen shifts between January 25, 2025, and February 25, 2025. The Nurse Educator confirmed during interviews that these CNAs did not complete the necessary training hours. The Director of Nursing also stated that all CNAs should have their 12 hours of in-service training completed if they are working on the floor with residents.
Breach of Resident PHI Due to Inadequate Safeguarding
Penalty
Summary
The facility failed to safeguard clinical record information, resulting in a breach of privacy for a resident. During an observation, a Certified Medication Aide (CMA) left a computer screen open and a narcotic book visible, exposing a resident's personal health information (PHI) to unauthorized individuals. Additionally, a narcotic record was left face up on the counter at the nurses' station. A Licensed Practical Nurse (LPN) confirmed these observations, acknowledging that the computer screen, narcotic book, and narcotic record should not have been left accessible to unauthorized residents, visitors, and staff.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as R #46, who reported that a night shift CNA was hateful towards him and instructed him not to use his call light for the rest of the night. This incident was initially reported by the resident to CNA #2 during a lunch observation, who then informed the Unit Manager (UM) #1. However, there was no documentation in the nursing progress notes regarding this allegation, and the UM was not made aware of the incident. Further interviews revealed that the Licensed Practical Nurse (LPN) #1, the Director of Nursing (DON), and the Administrator (ADM) were also unaware of the incident. The ADM, who is the abuse coordinator, confirmed that the allegation should have been reported immediately to initiate a thorough investigation. The failure to report and investigate the allegation of abuse indicates a breakdown in the facility's protocol for handling such incidents, potentially putting residents at risk of adverse outcomes.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge planning for two residents, leading to significant deficiencies in their care. Resident #104 was discharged without the necessary home health services in place, despite physician orders and care plan notes indicating the need for such services. The facility's Social Services Director (SSD) and Social Services Assistant (SSA) were responsible for coordinating these services through a third-party company. However, due to a lack of communication and follow-up, the home health agency did not accept the resident's insurance, resulting in the resident being discharged without the required care. Interviews with the resident, her son, and facility staff confirmed that the necessary services were not established prior to discharge. Resident #122 was discharged from the facility without proper notice or intervention for her behaviors. She had called 911 due to not feeling well and was transported to the hospital. The facility decided not to allow her back due to her physical aggression towards staff, and she was given an immediate discharge notice at the hospital. Interviews with the Director of Nursing (DON), the resident's son, and the Administrator confirmed that the resident was not allowed to return to the facility due to safety concerns related to her behavior. These deficiencies highlight the facility's failure to ensure that residents are adequately prepared for discharge, either by securing necessary home health services or by providing appropriate notice and intervention for behavioral issues. The lack of communication and follow-up in both cases resulted in residents being discharged without the support and care they required, potentially leaving them vulnerable and without necessary assistance.
Hospice Services Provided Without Physician Orders
Penalty
Summary
The facility failed to meet professional standards of quality by providing hospice services to a resident without obtaining the necessary physician orders. The resident was admitted to the facility and began receiving hospice care services as indicated in their care plan. However, a review of the resident's physician orders revealed that there were no orders present for the hospice care services. During an interview, the Director of Nursing confirmed that the resident started hospice services on February 1st and acknowledged that physician orders should have been obtained prior to the initiation of hospice care, but they were not.
Inadequate Care Leads to Resident's Wound Development
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident, identified as R #114, to maintain her overall well-being. Observations and interviews revealed that the resident, who was non-responsive and slumped in her wheelchair, was not repositioned or had her brief changed frequently enough to prevent the development of a wound. The resident's son and daughter reported finding her in a wet or soiled brief during their visits, indicating a lack of timely care by the staff. The resident's care plans highlighted her risk for skin breakdown due to limited mobility and incontinence, necessitating regular repositioning and brief changes. The Wound Care Nurse confirmed that the resident developed a wound on her buttock area due to moisture accumulation in her brief, which was not changed as frequently as needed. The wound was first identified on 02/12/25 and was attributed to the resident not being assisted with changing positions and inadequate brief checks. The resident's medical history included significant impairments following a stroke, making her dependent on staff for all activities of daily living, including toileting and mobility, which were not adequately addressed by the facility.
Failure to Provide Fall Mat for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as R #58, was provided with a fall mat to reduce injury from falling, as outlined in the resident's care plan. R #58 was admitted with diagnoses including diabetes mellitus, repeated falls, and an acquired absence of the left leg above the knee. The resident's care plan, dated 12/12/24, specifically included the use of a fall mat to prevent falls. However, observations on 02/18/25 and 02/20/25 revealed that no fall mat was present beside the resident's bed, despite the resident having a history of falls from the bed to the floor, as documented in daily care notes on multiple occasions. The Director of Nursing confirmed the absence of the fall mat during an interview on 02/20/25.
Failure to Maintain Filled Portable Oxygen Tank
Penalty
Summary
The facility failed to ensure a portable oxygen tank was filled with oxygen for a resident who required respiratory care. The resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), reported that the portable oxygen tank leaked and did not hold oxygen, rendering it unusable. Despite informing several staff members about the issue, no action was taken to address the problem. A physician's order indicated the resident required 2 liters of oxygen via nasal cannula to maintain oxygen saturation levels above 92% as needed. During interviews, a Certified Medication Aide and a Registered Nurse confirmed that the portable oxygen tank was empty, acknowledging that it should always be full and ready for use.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure proper storage and administration of medications, as observed during a survey. On February 24, 2025, an inspection of the south side medication cart revealed five unidentified loose pills in the second drawer, indicating improper storage. Additionally, a narcotic medication, Pregabalin, was signed out as administered to a resident but was still present in the medication card, suggesting it was not given as recorded. During an interview, a Certified Medication Aide (CMA) confirmed the presence of the loose pills and admitted to signing out the Pregabalin without administering it, contrary to the Medication Administration Record (MAR). The Director of Nursing (DON) acknowledged that medication carts should be checked daily, loose medications discarded, and any unadministered medications reported and documented, as failing to do so constitutes a medication error.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature for a resident reviewed for meal quality. During an interview, the resident reported that the food was often cold when delivered to his room for lunch. An observation of the lunch meal revealed that the temperatures of the tamale, black beans, and coleslaw were 117, 110, and 112 degrees Fahrenheit, respectively. These temperatures were confirmed by the Dietary Manager and the DC to be below the appropriate serving temperature of 135 degrees Fahrenheit or higher.
Failure to Follow Resident's Food Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, specifically regarding their dislike for eggs. During an interview, the resident expressed dissatisfaction with being served cold eggs for breakfast, which they did not like. An observation confirmed that the resident was served eggs, which they left uneaten. A review of the resident's meal ticket showed no indication of their dislike for eggs. The Dietary Manager, responsible for interviewing residents about their food preferences upon admission and reviewing them quarterly or as needed, was unaware of the resident's aversion to eggs.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to ensure the completeness of medical records for a resident, identified as R #89. Upon review, it was found that R #89's Electronic Medical Record (EMR) did not contain a Pre-Admission Screening and Resident Review (PASRR), which is a federally required document for individuals admitted to Medicaid-certified nursing facilities. The absence of this document was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the PASRR should have been included in the resident's admission records. This oversight in maintaining complete medical records could impede the staff's ability to provide competent and comprehensive care to the resident.
Lack of Coordinated Hospice Care Plan
Penalty
Summary
The facility failed to ensure collaboration between the facility and hospice services for a resident receiving hospice care. The deficiency was identified through a record review and interviews, revealing that a coordinated plan of care was not developed for the resident. The resident's admission Minimum Data Set (MDS) indicated they were on hospice care, but there was no hospice communication documentation in the medical record. The Director of Nursing in Training (DON-IT) mentioned that a hospice binder, which should contain written communication and the coordinated plan of care, was not available at the nurse's station or in medical records. The Director of Nursing (DON) confirmed the absence of hospice communication documentation, which should have been present.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance with bathing and showering, which is a critical aspect of maintaining personal hygiene and performing activities of daily living (ADLs). The resident, who was admitted with diagnoses including unspecified dementia, urinary incontinence, chronic respiratory failure with hypoxia, and nonrheumatic aortic stenosis, was scheduled to receive showers on Mondays and Thursdays. However, records indicate that the resident did not receive a shower from July 11, 2024, through August 11, 2024, with only one documented refusal on July 18, 2024. On several other dates, staff either marked the shower as 'not applicable' or failed to document whether the shower was completed. The lack of documentation and failure to provide scheduled showers suggest a breakdown in the facility's processes for ensuring residents receive necessary care. The Director of Nursing (DON) acknowledged the issue and noted that a new system had been implemented to ensure compliance with shower schedules. However, the deficiency occurred before this system was put in place, indicating that the previous system was inadequate in ensuring that residents received the care they needed. The failure to provide scheduled showers could lead to a decline in the resident's ability to maintain personal hygiene, which is essential for their overall health and well-being.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is crucial for assessing health status in nursing home residents. The resident was admitted with a history of sepsis, urinary tract infection, benign prostatic hyperplasia, and obstruction and reflux uropathy. However, discrepancies were found in the documentation regarding the presence of an indwelling catheter. The resident's face sheet and nursing admission assessment indicated that the resident was not admitted with a catheter and was continent of bladder, while the MDS assessment inaccurately recorded the presence of an indwelling catheter. Further review of nursing progress notes revealed that the resident requested the re-insertion of a Foley catheter, which he had used for over a year, but was not retaining urine as per bladder scans. The resident eventually left the facility against medical advice, insisting on having the catheter reinserted. Interviews with the Director of Nursing confirmed that the MDS assessments were incorrect, as the resident did not have a catheter upon admission. This inconsistency between the MDS, nursing admission assessment, and hospital discharge documentation led to the deficiency.
Delayed Meal Service and Inconsistent Delivery in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received their meals in accordance with the scheduled meal times, as observed during a survey. The meal schedule indicated that breakfast should be served at 7:15 am, lunch at 12:00 pm, and dinner at 5:15 pm. However, on the day of observation, lunch meal carts were delivered significantly late to two different halls, with one cart arriving at 1:12 pm and the other at 1:27 pm. This delay resulted in one resident receiving their lunch at 1:28 pm, while their roommate did not receive a meal until 1:43 pm. Interviews with the Director of Nursing and dietary staff revealed that such delays were common, with the kitchen often forgetting to send trays or being backed up, leading to inconsistent meal delivery times. Additionally, another resident reported that their meals were consistently delivered late, and there were instances where staff forgot to send meals, resulting in the delivery of an empty plate. This resident could not recall the exact number of times or the last occurrence of receiving an empty plate. These observations and interviews highlight a pattern of meal delivery issues within the facility, potentially impacting residents' nutritional intake and satisfaction with their care.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for at least 8 hours during each 24-hour period, as required. This deficiency was identified through a review of the facility's staffing schedule for the months of April, May, June, and July 2024, which revealed multiple days where no RN was scheduled to provide direct patient care. Specifically, the absence of an RN was noted on several days across these months. During an interview on August 15, 2024, the Scheduling Manager and the Administrator acknowledged the issue, citing a shortage of nurses as the reason for the lapses in RN coverage. This deficiency potentially affects all 114 residents in the facility, as it may result in them not receiving the necessary services. The report does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Failure to Maintain Accurate Resident Weights
Penalty
Summary
The facility failed to maintain accurate weights for a resident, which is a deficiency in meeting professional standards of quality. The resident in question was admitted with several diagnoses, including altered mental status, Parkinson's disease, ulcerative chronic proctitis, vascular dementia, and severe protein-calorie malnutrition. According to the physician's orders, the resident was supposed to be weighed weekly for four weeks and then monthly. However, the medical record only contained one weight entry, indicating a failure to follow the prescribed weight monitoring schedule. Interviews with the Director of Nursing (DON) and the Restorative Aide (RA) revealed a lack of clarity and communication regarding the responsibility for weighing residents. The DON stated that residents should be weighed weekly upon admission, but this was not done. The RA mentioned that the restorative program, which began in March, was responsible for weighing residents, but she was unaware if weights were being recorded before the program started. This lack of adherence to the weight monitoring protocol could lead to inadequate assessment of the resident's nutritional status.
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Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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