Sandia Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 2216 Lester Drive Ne, Albuquerque, New Mexico 87112
- CMS Provider Number
- 325032
- Inspections on file
- 35
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Sandia Ridge Center during CMS and state inspections, most recent first.
Staff failed to keep medication and treatment carts locked and attended on three hallways, resulting in unsecured medications and supplies. A medication cart on one unit was observed unlocked and unattended outside a room, and an LPN confirmed it was her cart and that it should have been locked. Another medication cart on a different unit was also found unlocked and unattended, which a CNA confirmed. A treatment cart on a third unit was similarly observed unlocked and unattended outside a room, and an RN acknowledged it should have been locked before leaving the area. The DON stated that medication and treatment carts are expected to be locked at all times when not in use or when nurses are away from them.
Staff failed to protect residents' PHI by leaving multiple types of documents containing identifiable information, including CNA shower lists, face sheets, and vital sign lists, unattended and exposed on treatment/medication carts in hallways. These documents were observed on several occasions on different units, visible to anyone passing by. An LPN, an RN, and a CMA each confirmed that the documents were left exposed and acknowledged that resident-identifiable information and PHI should not be left unattended.
A resident admitted for orthopedic aftercare following surgical amputation, with a history of kidney transplant and difficulty walking, arrived from the hospital with discharge orders for non–weight-bearing status to the right lower extremity and a requirement for a private room due to immunocompromised status from immunosuppressive medication. These orders were not transcribed into the facility’s physician orders, and thus non–weight-bearing and isolation precautions were not implemented. The DON reported that admission orders from the hospital were expected to be reviewed and clarified before arrival, but acknowledged that the admission nurse did not complete this review, leading to the omission.
A resident admitted with recent surgical amputation, kidney transplant status, mobility limitations, osteomyelitis, and multiple high‑risk medications (including azathioprine, Eliquis, gabapentin, insulin, and IV antibiotics for VRE and other infections) did not have a complete baseline care plan developed within 48 hours of admission. Record review showed the baseline care plan failed to address pain management, antibiotic use, weight‑bearing status, anticoagulant use, and hypoglycemia related to insulin therapy. The DON confirmed in interview that these areas were omitted and that the baseline care plan was not completed as required within the first 48 hours after admission.
A resident receiving hospice care did not have physician orders for hospice services in the medical record. Review of the chart showed signed hospice documents and confirmation from the Social Services Director that the resident had been admitted to a hospice agency, but no corresponding physician order was found. The DON acknowledged that physician orders for hospice should have been present and confirmed they were missing from the resident’s record.
A resident who required assistance with ADLs was not provided with scheduled showers as outlined in the care plan, which called for twice-weekly baths/showers and as-needed bathing. Review of the EHR showed that over multiple weeks the resident received or was offered significantly fewer showers than scheduled, including a period with no documented shower offers at all. The UM confirmed that the showers did not occur as scheduled and stated that CNAs are expected to provide and document showers or refusals in the EHR after each opportunity.
Surveyors observed a drink and snack cart with a pitcher of milk placed on ice that was not labeled or dated, which a CNA confirmed. In the kitchen, two dietary aides were seen preparing food without required beard restraints. The Dietary Manager acknowledged that all items leaving the kitchen are expected to be labeled and dated and confirmed that the aides were not wearing beard restraints as required.
Surveyors found that restrooms in four resident rooms had vinyl baseboard coverings in disrepair, including multiple gaps and holes of varying lengths around the walls and behind toilets. In one room, gaps of about six and seven inches extended along both sides of the wall and behind the toilet, while other rooms had smaller gaps and holes ranging from about one to four inches near and beside the toilets. The MD confirmed the presence of these gaps and holes in all four identified rooms and acknowledged that the vinyl baseboards required immediate repair to prevent insects and pests from entering.
A resident with a G-tube, indwelling catheter, unhealed pressure ulcers, and ongoing wound care orders required Enhanced Barrier Precautions (EBP), but staff failed to post EBP signage at the room entrance during multiple observations. The resident had active orders for enteral feeding, catheter management, and daily wound care. The ADM and DON both acknowledged that the resident met criteria for EBP and that signage is used to inform staff of required precautions, yet no such signage was present, demonstrating a failure to implement the infection prevention and control program.
The facility failed to ensure meals were palatable and served at an appetizing temperature, as multiple residents reported that their food was consistently or often cold, sometimes arriving after long delays and no longer warm enough to enjoy. One resident described the food as horrible and stopped requesting reheating because it did not improve the temperature, while another reported inconsistent meal temperatures. During a lunch observation, plates for two residents were cool to the touch. The Dietary District Manager acknowledged awareness of complaints about cold food, and the Administrator confirmed awareness of ongoing food temperature problems despite the use of plate bases and warmers.
Multiple residents did not receive scheduled assistance with ADLs, including bathing, showering, and nail care. Documentation and interviews confirmed that residents were not consistently offered or given baths/showers as scheduled, and requests for nail care were not addressed in a timely manner. Staff and family members observed lapses in personal hygiene, and records were incomplete or missing for required care activities.
A resident with dementia and a history of traumatic brain injury was found outside the facility and had a Wander Guard device placed on their wheelchair without a provider order or care plan documentation. The device was applied before any order was obtained, and staff confirmed that nurses could place such devices without provider authorization or documentation of elopement risk.
A resident with dementia, a history of traumatic brain injury, and poor safety awareness was ordered to have a Wander Guard elopement device, but the care plan did not document the elopement risk or the device order. This omission was confirmed by the Assistant DON during review.
Nursing staff did not follow protocol to preserve the scene of a suspicious death, as they removed a bag from a resident's head, cleaned and moved the body, and discarded evidence before contacting OMI and police. This action was not in accordance with professional standards or state requirements, as confirmed by facility leadership and the OMI investigator.
A resident with dementia, traumatic brain injury, and a history of homelessness was able to leave the facility unsupervised after removing a Wander Guard device, despite staff being aware of repeated elopement attempts and the resident's poor safety awareness. The care plan did not address elopement risk or include necessary interventions, and staff failed to provide adequate supervision, resulting in the resident being missing for over 24 hours.
A resident with acute infective endocarditis and bacteremia did not receive prescribed IV antibiotics on time due to the facility's failure to ensure timely delivery from the pharmacy. The resident's medication administration record showed missed doses of Ampicillin and Ceftriaxone, leading to a hospital transfer. The ADON confirmed the importance of timely administration to maintain therapeutic levels.
A resident with dementia and coordination issues experienced a mechanical fall, resulting in fractures and hospital admission. The facility failed to investigate or report the incident to the state agency within the required timeframe, as the Administrator was unaware of the fall and injuries. This oversight left the resident at risk of further harm.
A facility failed to investigate and report an injury of unknown origin for a resident with multiple diagnoses, including dementia and fractures. The resident was transferred to a hospital for worsening edema, where it was revealed that a fall had occurred, but no fall was reported within the facility. Interviews with staff indicated a lack of awareness and failure to conduct an investigation or report the incident to the state agency.
A resident with multiple chronic conditions sustained bruises on both hands after a Wound Care Nurse mistakenly believed the resident had her cell phone and forcefully took it, despite the resident's refusal. The incident was witnessed by the ADON, who described the interaction as inappropriate. The resident was very upset by the incident, and the nurse later returned the phone and apologized.
The facility failed to document the daily temperature of a refrigerator used to store resident snacks in the 100 unit, potentially affecting all 23 residents in that unit. During an observation, it was noted that the refrigerator contained food items and snacks for residents, but a review of the temperature log revealed that staff did not document the refrigerator's temperature on several dates. A CNA confirmed the lapse in documentation.
A resident's family reported finding the resident in a very wet and smelly brief, but the grievance was not documented or investigated. Interviews with the DON and ADM confirmed that the incident should have been reported and investigated, but it was not.
The facility failed to keep medications in original packaging, store expired supplies separately, and consistently record refrigerator temperatures for medications and vaccines. Expired medications were also found mixed with unexpired ones. The DON confirmed these lapses in protocol.
The facility failed to treat residents with respect and dignity by not ensuring staff knocked on residents' bedroom doors before entering. A CNA and an RN entered rooms without knocking, and both confirmed they should have knocked. The DON stated that staff are expected to knock, announce their intention to enter, and wait for permission before entering a resident's room.
The facility failed to invite residents to care plan meetings, as evidenced by two residents who were not notified or invited to their care plan conferences. Staff interviews revealed systemic issues, including lack of documentation and verbal notifications without proper records.
The facility staff did not report an incident where a resident was found unresponsive with drug paraphernalia. Narcan was administered, and the resident responded but refused ER transport. The Administrator did not report the incident, believing it was not a drug overdose.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease and dependence on renal dialysis. The care plan lacked critical details such as dialysis fistula care, monitoring for infections, and specific goals and interventions. The deficiency was confirmed by the DON.
The facility failed to inform a resident or their representative about the risks and benefits of buspirone, a psychotropic medication prescribed for anxiety and behaviors. The resident's medical records lacked documentation of informed consent, and the DON confirmed that a signed consent form was missing.
A resident, who was independent and had intact cognition, wanted to shower daily and independently, but the facility's policy required staff presence during showers. The staff were unable to accommodate her preferred shower times, leading to her dissatisfaction and a complaint to Social Services. The facility's policy and staffing constraints prevented her from showering according to her preference.
Unlocked and Unattended Medication and Treatment Carts on Multiple Units
Penalty
Summary
The facility failed to ensure medications and biologicals were properly stored and secured when multiple medication and treatment carts were left unlocked and unattended on the 200, 300, and 400 hallways. On 03/17/26 at 9:38 a.m., a medication cart on the 300 unit was observed unlocked and unattended outside a resident room, and at 9:40 a.m. an LPN confirmed the cart was hers, acknowledged it was unlocked and unattended, and stated she should have locked it. At 9:42 a.m., a medication cart on the 400 unit was observed unlocked and unattended outside a resident room, and at 9:43 a.m. a CNA confirmed the cart was left in that condition. At 9:49 a.m., a treatment cart on the 200 unit was observed unlocked and unattended outside a resident room, and at 9:50 a.m. an RN confirmed the treatment cart was left unlocked and unattended and stated the nurse should have locked it prior to leaving the area. On 03/19/26 at 11:07 a.m., the DON stated that medication carts should always be locked when nurses are away from the cart and further stated it is an expectation for nurses to keep medication and treatment carts locked at all times when not in use.
Unattended PHI Documents Left Exposed on Treatment Carts
Penalty
Summary
The facility failed to safeguard residents' personal health information by leaving documents containing resident-identifiable information unattended and exposed on treatment/medication carts in hallways. On 03/17/26 at 9:40 a.m., a stack of CNA shower lists with complete resident information was observed lying on top of a treatment cart outside a resident room, unattended and visible to the public. At 9:42 a.m., an LPN confirmed that the CNA shower list was exposed to public view and acknowledged that resident-identifiable information should not be left unattended. On 03/19/26 at 8:38 a.m., a stack of patient face sheets with resident information was observed on top of a treatment cart outside a resident room, again left unattended and exposed to public view. At 8:40 a.m., an RN confirmed that a face sheet was left exposed and unattended and stated that personal health information should not be left unattended. On 03/18/26 at 8:46 a.m., a stack of resident vital sign lists containing resident information was observed on top of a treatment cart on the 400 wing, unattended and visible. At 8:52 a.m., a CMA confirmed that the resident vitals list was exposed to public view and unattended, and acknowledged that resident-identifiable information should not be left unattended.
Failure to Implement Hospital Discharge Orders for Weight-Bearing and Isolation Status
Penalty
Summary
The facility failed to ensure that physician orders from a transferring hospital regarding weight-bearing status and isolation needs were accurately transferred and implemented for one admitted resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status requiring immunosuppressive medication, and difficulty in walking. Hospital discharge orders dated 10/09/25 included a non–weight-bearing order for the right lower extremity and a requirement for a private room due to immunocompromised status related to the kidney transplant. Review of the resident’s physician orders at the facility showed that the non–weight-bearing status for the right lower leg and the isolation precautions related to immunosuppressive medication were not present. In an interview, the DON stated that the resident should have had these physician orders in place per the hospital discharge instructions and that her expectation was that all hospital admission orders be reviewed and clarified before the resident’s arrival. The DON confirmed that the admission nurse did not review and clarify these admission orders, and as a result, they were not implemented.
Failure to Complete Comprehensive Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop a complete baseline care plan within 48 hours of admission for one resident. The resident was admitted and later discharged within a few days, with documented diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status, difficulty walking, reduced mobility, and acute osteomyelitis of the right ankle and foot. Physician orders at admission included multiple high‑risk medications and treatments: azathioprine for immunosuppression, Eliquis as an anticoagulant, gabapentin for neuropathic pain, insulin for diabetes, and IV antibiotics (linezolid for VRE and meropenem). These orders and diagnoses established several immediate clinical needs at the time of admission. Record review showed that the baseline care plan dated the day after admission did not address key areas related to the resident’s immediate needs, specifically pain management, antibiotic use, weight‑bearing status, anticoagulant use, and hypoglycemia related to insulin therapy. In an interview, the DON confirmed that the baseline care plan failed to include these elements and acknowledged that the baseline care plan should be completed within the first 48 hours of admission, which did not occur as required. This omission formed the basis of the cited deficiency.
Failure to Obtain Physician Orders for Hospice Services
Penalty
Summary
The facility failed to obtain physician orders for hospice services for one resident receiving hospice care. Record review showed that this resident was admitted to the facility on an unspecified date, and review of the physician orders did not reveal any order for admission to hospice services. The resident’s electronic health record contained signed hospice documents dated 02/24/26, and the Social Services Director stated in an interview that the resident was admitted to a named hospice agency on that same date. In a separate interview, the DON confirmed that the resident should have had physician orders for hospice services and acknowledged that no such orders were available or present in the resident’s medical record. This deficiency was identified for one of three residents reviewed for hospice services, based on the absence of required physician orders despite documentation and staff statements confirming the resident’s enrollment in hospice care.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers for one resident who required assistance with activities of daily living (ADLs). Record review showed that this resident was admitted on 10/13/25 and discharged on 01/07/26, with a care plan indicating the resident should be offered a bath/shower twice weekly on Tuesdays and Thursdays and as needed. Review of the electronic health record (EHR) from 09/01/25 through 11/30/25 revealed that from 10/13/25 through 10/31/25, the resident was offered or received only 2 baths/showers out of 6 scheduled opportunities, and from 11/01/25 through 11/30/25, the resident was offered or received 0 baths/showers out of 2 scheduled opportunities. During an interview on 03/19/26 at 11:54 a.m., the Unit Manager confirmed that the showers for this resident did not occur as scheduled. The Unit Manager also stated that the facility’s expectation is for CNAs to shower residents on their scheduled days and document in the EHR after each opportunity, whether the shower was given, missed, or refused. The deficient practice was noted as likely to result in residents feeling dirty and neglected, resulting in isolation.
Failure to Label Milk and Use Beard Restraints During Food Preparation
Penalty
Summary
Surveyors identified deficiencies in food storage and handling practices when a drink and snack cart outside a resident room was observed with an unlabeled and undated pitcher of milk sitting on a bucket of ice. A CNA confirmed that the milk on the cart was not labeled or dated. In a separate observation in the facility kitchen, two kitchen aides were seen preparing food without wearing beard restraints. During an interview, the Dietary Manager stated that his expectation is that kitchen staff label and date every item leaving the kitchen, which did not occur in this instance, and confirmed that the two kitchen aides were not wearing beard restraints as required when in the kitchen. No specific resident medical histories or conditions were mentioned in relation to these deficiencies.
Damaged Vinyl Baseboards in Multiple Resident Restrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident restrooms in good repair and free from damage, specifically related to vinyl baseboard coverings in four resident rooms on the 200, 300, and 400 halls. During random room observations, surveyors noted that in one room, the vinyl baseboard covering was in disrepair with gaps measuring approximately six inches along the bottom left portion of the wall, extending through the corner and continuing behind the toilet, and an additional gap of approximately seven inches along the right side of the wall, also continuing behind the toilet. In another room, the vinyl baseboard covering had a hole measuring approximately one and a half inches in the corner to the right of the toilet and another hole of approximately two inches on the wall to the left of the toilet. Further observations showed that in a third room, the vinyl baseboard covering was in disrepair with a gap of approximately two inches on the wall to the left of the toilet and a one-inch gap on the wall to the right of the toilet. In a fourth room, a gap of approximately four inches in length was present on the wall to the left of the toilet. During an interview, the Maintenance Director confirmed the presence of gaps and holes in the vinyl baseboard coverings in the restrooms of rooms 210, 305, 307, and 405 and acknowledged that the vinyl baseboards should be repaired immediately to prevent insects and pests from entering through the gaps and holes.
Failure to Post Enhanced Barrier Precautions Signage for High-Risk Resident
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not posting required Enhanced Barrier Precautions (EBP) signage for a resident who met criteria for these precautions. The resident was admitted on 12/17/25 and had diagnoses and conditions including gastronomy status, an indwelling catheter, a swallowing disorder requiring a feeding tube, unhealed pressure ulcers, and a continued risk for developing pressure ulcers requiring wound care. Physician orders dated 03/07/26 included enteral feeding every day and night shift, as-needed indwelling catheter changes when occluded or leaking, and daily wound care for pressure ulcers with specific cleansing and dressing instructions. During multiple observations on 03/09/26 and 03/10/26, the resident was noted to have an indwelling Foley catheter and a feeding tube, and there was no EBP signage posted at the entrance to the room indicating that enhanced precautions were required. The Administrator stated that the resident required EBP because of the indwelling catheter and feeding tube and confirmed that there was no sign posted, acknowledging that there should have been one. The DON also stated that the resident required EBP for direct care and that signage is used to inform staff about required precautions and the type of precautions needed. These observations and interviews showed that the facility did not implement appropriate EBP signage for this resident as part of its infection prevention and control program.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable and served at an appetizing temperature for all six residents reviewed, with the potential to affect all 128 residents in the facility. Multiple residents reported that their meals were consistently or often cold when they were supposed to be hot. One resident stated they ate only what they could tolerate because the food often arrived too cold to enjoy. Another resident reported that room trays sometimes took a long time to reach the rooms, and others stated their meals were often not warm enough or were already cold by the time the tray reached them. One resident described the food as horrible and said they no longer asked to have it warmed up because it had not helped in the past, and another resident reported that meal temperatures were inconsistent, with some meals arriving cold and others not. During observation of a lunch meal tray delivery to one unit, the plates for two of the reviewed residents were noted to be cool to the touch, supporting the residents’ reports of inadequate food temperatures. In interviews, the Dietary District Manager acknowledged being aware of residents’ complaints about cold food served at the facility. The Administrator stated that the facility used plate bases and plate warmers to help keep hall tray meals warm and acknowledged awareness of a problem with food temperatures. These interviews and observations demonstrate that the issue of cold meals was known to facility leadership and dietary management while residents continued to receive meals that were not served at an appetizing temperature.
Failure to Provide Scheduled ADL Assistance and Personal Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, specifically in the areas of bathing, showering, and nail care. Documentation revealed that one resident, who had physical and cognitive impairments and was scheduled for baths or showers three times a week, did not consistently receive the scheduled number of baths or showers over several months. Interviews with staff and the resident's power of attorney confirmed that the resident was not offered or given enough baths/showers as scheduled, and family members observed the resident to be visibly dirty and with a foul odor during visits. Staff also confirmed that all baths/showers and refusals should be documented, but shower sheets were missing for the relevant timeframes. Another resident reported not receiving hair or nail care unless provided by family, and documentation showed a lack of records regarding bathing, with only one refusal documented out of multiple opportunities. Staff interviews confirmed that residents should be offered showers multiple times per week, regardless of hospice status, but this was not consistently done. A third resident and their family reported missed scheduled baths, and documentation supported that only one shower was recorded for the month, despite a schedule of three per week. The DON confirmed that documentation showed insufficient offers or provision of baths and showers for these residents. A fourth resident requested nail care, stating that staff would not allow her to have a nail clipper and that her nails were getting too long. Staff interviews revealed that the request had not been communicated to the appropriate personnel, and the resident continued to wait for nail care. The DON stated that the expectation is for staff to provide nail care when requested and to communicate a timeframe if it cannot be done immediately. The lack of timely and documented ADL assistance, including bathing and nail care, was confirmed through interviews, record reviews, and direct resident and family reports.
Unauthorized Use of Physical Restraint Without Provider Order
Penalty
Summary
A resident with diagnoses including dementia, a history of traumatic brain injury, and homelessness was admitted to the facility and was not identified as an elopement risk according to the Elopement Risk Evaluation. Despite this, a daily care note documented that the resident was found in the parking lot and subsequently had a Wander Guard device placed on their wheelchair. The resident expressed a desire to leave the facility and stated they did not want to be there. A provider order for the Wander Guard was not entered until several days after the device was placed. The resident's care plan did not include documentation regarding elopement risk or the use of the Wander Guard. The Assistant Director of Nursing confirmed that the Wander Guard was placed prior to the provider order and acknowledged that nurses had access to and could place Wander Guards without a provider order. There was no documentation explaining who placed the device or the rationale for its use prior to the order.
Failure to Revise Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan for one resident who was identified as an elopement risk. Record review showed that the resident had diagnoses including dementia, a history of traumatic brain injury, and homelessness, and required assistance with personal care. A provider order was present for staff to place a Wander Guard elopement device on the resident due to poor safety awareness. However, the resident's care plan did not include documentation of the elopement risk or the order for the Wander Guard. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that there was no care plan addressing the resident's elopement risk or the use of the Wander Guard device.
Failure to Preserve Scene of Suspicious Death Prior to Notification of Authorities
Penalty
Summary
Nursing staff failed to maintain the scene of a suspicious death in accordance with professional standards and state requirements. A resident with multiple fractures and an aortic aneurysm was found unresponsive in his room with a bag over his head and tied at the neck. The nurse observed no signs of life, removed the bag, and pronounced the resident dead. The nurse then notified the health provider, facility administration, and the Office of Medical Investigator (OMI) after the body had already been disturbed. Staff proceeded to clean and move the body, remove the Foley catheter, and change the sheets before the arrival of police or OMI. Upon arrival, police found the body covered with a sheet and learned that staff had discarded the bag and string, and had already cleaned the scene. The Assistant Director of Nursing confirmed that the expectation was for staff to contact OMI before moving or disturbing the body, which was not followed in this case. The OMI investigator also stated that the nurse was instructed to leave the scene untouched and contact police immediately, but this was not done prior to the scene being altered.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for a resident identified as being at risk for elopement. The resident, who had diagnoses including dementia, a history of traumatic brain injury, and homelessness, exhibited impaired cognitive function and poor safety awareness. Despite multiple documented incidents of the resident attempting to leave the facility and expressing a desire to do so, the care plan did not address elopement risk or include interventions such as the use of a Wander Guard or increased supervision. Although a provider order was eventually entered for a Wander Guard, the resident refused to wear it and was able to remove it without staff intervention. On the day of the incident, the resident was last seen after lunch and was later found to be missing, with staff unable to locate him after searching the facility and surrounding areas. The resident had exited the building by pressing a button that unlocked the front door, after having cut off the Wander Guard device, which prevented the alarm from sounding. Staff were aware of the resident's elopement risk and previous attempts to leave, but failed to ensure adequate supervision or monitoring to prevent the resident from leaving the facility unsupervised.
Failure to Administer IV Antibiotics on Time
Penalty
Summary
The facility failed to ensure that a resident received prescribed intravenous (IV) medications on time, as per professional standards of practice. The resident was admitted with multiple diagnoses, including acute infective endocarditis and bacteremia, and was prescribed Ampicillin and Ceftriaxone to be administered intravenously. However, the facility did not provide and administer these antibiotics as ordered by the prescriber. The medication administration record indicated that several doses of Ampicillin and Ceftriaxone were not administered due to the medications not being delivered by the pharmacy. The resident's daily notes revealed multiple entries indicating that the IV solutions were awaiting delivery, and the family expressed concern about the delay in administration. The resident was eventually transferred to a hospital due to not receiving the prescribed antibiotics, as confirmed by the hospital emergency room care note. The Assistant Director of Nursing confirmed that the IV antibiotics were ordered but not available for multiple doses, emphasizing the importance of timely administration to maintain therapeutic levels, especially given the resident's diagnosis of endocarditis.
Failure to Report Resident Injury of Unknown Source
Penalty
Summary
The facility failed to report a resident's injury of unknown source to the State Agency within the required 24-hour timeframe. The resident, identified as R #4, was admitted to the facility with multiple diagnoses, including pain in the left hip, dementia, and lack of coordination. After a mechanical fall, the resident was admitted to the hospital with a fracture of the left femur and patella. Despite the resident's hospital admission and subsequent return to the facility with surgical incisions, the facility did not conduct an investigation or report the incident to the state agency. The Administrator admitted to being unaware of the fall and the extent of the resident's injuries. Consequently, no investigation was conducted, and no initial or follow-up reports were submitted to the state agency. This oversight left the resident at risk of further injuries, as the facility did not take the necessary steps to address and report the incident as required by regulations.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and report within five working days an injury of unknown origin for a resident. The resident was admitted with multiple diagnoses, including pain in the left hip, dementia, and lack of coordination. After being readmitted to the facility with new diagnoses of fractures in the left femur and patella, the resident was transferred to a hospital due to worsening edema. Hospital records indicated that the resident had fallen a few days prior, resulting in left hip pain, but there was no record of a fall reported within the facility. Interviews with the Assistant Director of Nursing and the Administrator revealed that there was no awareness of the fall or the extent of the resident's injuries. The Administrator acknowledged that no investigation was conducted, and no report was submitted to the state agency as required. This lack of action prevented the state agency from appropriately triaging the allegation for further investigation.
Resident Sustains Bruises Due to Staff Misconduct
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where a resident sustained bruises on both hands. The resident, who had multiple diagnoses including Type 2 diabetes mellitus with a foot ulcer, chronic respiratory failure with hypoxia, adjustment disorder with mixed anxiety and depressed mood, and chronic systolic heart failure, was involved in an altercation with the Wound Care Nurse (WCN). The incident occurred when the WCN mistakenly believed the resident had her cell phone and attempted to retrieve it by force, despite the resident's refusal to hand it over. This resulted in a struggle, during which the resident sustained bruises on both hands. The incident was witnessed by the Assistant Director of Nursing (ADON), who observed the WCN forcefully taking the phone from the resident, causing a loud and noticeable disturbance in the dining area. The resident expressed being very upset by the incident, and the ADON described the interaction as inappropriate. The Licensed Practical Nurse (LPN) who documented the incident noted the bruises on the resident's hands and confirmed the WCN's actions. The WCN later realized the phone was not hers and returned it to the resident, apologizing for the mistake.
Failure to Document Refrigerator Temperatures
Penalty
Summary
The facility failed to document the daily temperature of a refrigerator used to store resident snacks in the 100 unit, potentially affecting all 23 residents in that unit. During an observation on 07/23/24, it was noted that the refrigerator, located in the dining area, contained food items and snacks for residents. A temperature log was attached to the front of the refrigerator. However, a review of the log for July 2024 revealed that staff did not document the refrigerator's temperature from 07/05/24 through 07/07/24 and from 07/13/24 through 07/23/24. During an interview on 07/23/24, CNA #1 confirmed that the refrigerator contained resident snacks and foods and that staff were expected to monitor and record the refrigerator temperature on the log. CNA #1 verified that the temperature was not recorded on the specified dates, indicating a lapse in the facility's procedure for ensuring proper food storage.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to recognize, investigate, and respond to a grievance reported by the family of a resident. The resident, who was admitted with multiple diagnoses including sepsis, altered mental status, disorientation, and difficulty walking, was found by his wife and daughter in a very wet and smelly brief. This incident was reported to the evening nurse on duty, but no grievance report was filed for the month of April 2024 regarding this issue. Interviews with the resident's daughter, the Director of Nursing (DON), and the Administrator (ADM) revealed that the incident was not reported to the DON or the ADM, and no investigation was conducted. The DON and ADM both confirmed that the incident should have been reported and investigated as a grievance, but it was not. This failure to address the grievance is likely to result in residents feeling that their concerns do not matter and their rights are not being honored.
Medication and Supply Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were kept in their original packaging, as observed on the 300 medication cart where a small medication cup was filled with unlabelled round pills. The Certified Medication Aide (CMA) confirmed that the pills were Tylenol 325 mg, which had been removed from their original container for convenience. The Director of Nursing (DON) acknowledged that staff should not take medication out of the original container and store it in the top of the medication cart. Additionally, expired supplies were found in the medication room, including lubricating jelly, ultrasound gel, syringes, IV start kits, and central line trays, which the DON confirmed should have been removed by nursing managers responsible for checking expiration dates. The facility also failed to consistently record refrigerator temperatures for both medication and vaccine storage. Temperature logs for the medication refrigerator showed multiple instances where temperatures were not documented, and the refrigerator contained insulin medications. Similarly, the vaccine refrigerator logs had missing temperature entries. The DON confirmed that staff were expected to fill out these logs daily. Furthermore, expired medications were found mixed with unexpired medications in the 500 medication cart, including a gemfibrozil tablet that had expired. The DON stated that nursing staff were supposed to check their medication carts for expired medications at least once a month, but this had not been done effectively.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to treat residents with respect and dignity by not ensuring staff knocked on residents' bedroom doors before entering. For Resident #22, a Certified Nursing Assistant (CNA) entered the room twice without knocking, and the CNA confirmed she should have knocked. For Resident #74, a Registered Nurse (RN) entered the room without knocking, and the resident expressed that it bothered her when staff did not knock. The RN confirmed that staff should knock and wait for permission before entering. The Director of Nursing (DON) stated that staff are expected to knock, announce their intention to enter, and wait for permission before entering a resident's room.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents or their representatives were invited to care plan meetings, as evidenced by the cases of two residents. For Resident #48, a review of progress notes from January 1, 2024, to April 9, 2024, revealed no documentation of a care conference or an invitation to a care plan meeting. During an interview, Resident #48 stated that he used to attend care plan conferences but was no longer invited. Similarly, for Resident #78, medical records indicated no documentation of a care conference or an invitation in the last three months. Resident #78 stated she was unaware of the care plan meetings because staff did not invite her and expressed a desire to attend them. Interviews with facility staff revealed systemic issues in the care planning process. The Administrator admitted that care plan meetings and conferences were not conducted as required, and notifications were not sent out because care plans were not scheduled. The Social Services Assistant mentioned that residents were notified by placing a letter on their bed but was unsure if copies were kept. The Social Services Director acknowledged being behind on care plans due to a lack of help and confirmed that notifications were not sent out because care plans were not completed. She also stated that Resident #78's care plan meetings were verbally communicated, and no sign-in sheet was maintained.
Failure to Report Unresponsive Resident Incident
Penalty
Summary
The facility staff failed to report an incident to the state agency where a resident was found unresponsive outside in a wheelchair with burnt foil, two straws, and a lighter at his feet. The staff administered two doses of Narcan, and the resident began to respond. Although the resident refused transport to the emergency room, the care plan was updated to address possible substance abuse, and a drug screen was conducted, which came back negative. The Administrator did not report the incident to the state agency, believing it was not a drug overdose since the resident's vitals normalized and the drug screen was negative.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with end-stage renal disease and dependence on renal dialysis. The care plan, dated 02/12/24, did not address critical aspects of dialysis care, including the dialysis fistula, care bruit, thrill, monitoring for signs and symptoms of infections, bleeding, and any abnormalities regarding the site. Additionally, the care plan lacked specific goals and interventions related to dialysis. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan did not include necessary dialysis-related information.
Failure to Inform and Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about the risks and benefits of psychotropic medications. Specifically, for one resident with diagnoses of dementia, major depressive disorder, and anxiety disorder, the staff did not provide information or obtain consent for the administration of buspirone, a medication prescribed for anxiety and behaviors. The resident's medical records lacked documentation that the resident or their representative was informed about why the medication was prescribed, what condition it treated, potential side effects, and alternative treatments. During an interview, the Director of Nursing (DON) confirmed that there should have been a signed consent form for the use of buspirone, which was not present in the resident's file. The existing consent form only covered psychotropic medications prescribed since 2021, and a new consent form should have been signed when buspirone was later prescribed. This oversight could result in residents potentially receiving unnecessary treatment or medication without being fully informed of the associated risks and benefits.
Failure to Accommodate Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident was bathed according to her preference. The resident, who was independent and had intact cognition, expressed a desire to shower every day and stated she could do so independently. However, the facility's policy required staff presence during showers, and the staff were unable to accommodate her preferred shower times, which were usually in the afternoon. The resident's care plan indicated she required minimal assistance for activities of daily living, including bathing, but the facility's policy did not allow her to shower independently, leading to her dissatisfaction and a complaint to Social Services. Interviews with the staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's policy was to have staff present for all showers, and the staff found it challenging to accommodate the resident's preferred shower times. The Director of Nursing acknowledged the resident's preference but felt that the resident needed supervision during showers for safety reasons. Despite the resident's ability to shower independently, the facility's policy and staffing constraints prevented her from showering according to her preference.
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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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