Silver City Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver City, New Mexico.
- Location
- 3514 Fowler Avenue, Silver City, New Mexico 88061
- CMS Provider Number
- 325091
- Inspections on file
- 30
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Silver City Care Center during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen refrigerator, freezer, and pantry were not stored under sanitary conditions, with multiple products lacking dates, covers, or proper sealing, and some bearing outdated dates. Undated or improperly stored items included butter blocks, Jello, pears, peanut butter bar dessert, sliced ham, baked pineapple cake, Salsbury steak, chicken patties, lemon meringue pie, pie crusts, and corn tortillas. The DM reported that staff are expected to date food upon delivery and opening, and to discard outdated items, but acknowledged that food without dates, without covers, not tightly sealed, and with outdated dates was present.
Surveyors found that care plans were not revised to reflect current MD orders and resident needs. One resident had an order for enteral feeding when oral intake was poor, but the feeding and related interventions were not added to the care plan. Another resident with thick, layered toenails had an order for regular nail checks and trimming, including documentation of refusals, yet the care plan did not address nail care or how staff manage the resident’s combative behavior during this care, as confirmed by a CNA and a UM. A third resident had an order for PRN O2 at 1–2 L/min via nasal cannula for low oxygen, but O2 therapy and interventions were missing from the care plan, which the Administrator acknowledged.
Surveyors found that performance evaluations were not completed as required for two CNAs. Review of personnel files showed that each CNA, hired more than several months earlier, had no documented performance evaluation. In an interview, the administrator confirmed that no evaluations had been completed for these CNAs, despite the facility’s expectation that CNA performance reviews be conducted at least annually.
Surveyors found that consultant pharmacist recommendations regarding psychotropic and antidepressant medications were not consistently followed by physicians, and when recommendations such as continuation at current dose or consideration of GDR were made, physicians did not document resident-specific benefit/risk analyses or rationales in the medical records. Several residents with dementia, agitation, depression, and anxiety were receiving atypical antipsychotics or escitalopram, and pharmacy reports repeatedly noted the increased risks associated with these drugs in dementia-related psychosis while recommending continuation or GDR. The DON acknowledged that the charts lacked specific benefit/risk analyses or rationales for not implementing GDR, despite her expectation that physicians would provide this documentation.
Multiple residents had inaccurate or incomplete documentation in their medical records, including one resident whose admission assessment incorrectly recorded them as edentulous despite visible broken teeth, two residents whose activity participation records lacked entries for church attendance and ordered one-to-one activities that staff reported were being provided, and another resident whose documented skin assessment stated there were no skin issues even though the resident had a visible elbow wound with an unchanged dressing. Staff interviews, including with the UM, AD, wound care nurse, and DON, confirmed that the documentation did not reflect the care and conditions actually observed.
A resident’s needs were not reasonably accommodated when the call light in the resident’s room was found hanging from a light fixture above the bed, approximately six feet from the floor, making it inaccessible. A CNA confirmed that the call light was positioned this way and that the resident could not reach it. The Administrator acknowledged that residents are expected to be able to reach their call lights.
Two residents did not receive accurate MDS assessments. One resident with visibly broken and discolored teeth, who reported needing multiple teeth pulled, was incorrectly coded on the admission MDS as edentulous. Another resident with a history of cerebral infarction had a CTA showing complete occlusion of one carotid artery and significant stenosis of the other, with corresponding diagnoses documented in a provider note, but these active vascular diagnoses were not entered on the subsequent Quarterly MDS. The MDS coordinator reported she had not been informed of the new diagnoses and that they should have been included.
A resident with a PEG tube had an active order for Jevity 1.2 via PEG four times daily, while a later order allowed a regular/liberalized pureed diet with nectar-thick liquids and supervised soft snacks. Staff interviews revealed that the resident had been eating all meals by mouth for an extended period and only received PEG feeding, if at all, when oral intake was less than half of the meal. The NP and DON confirmed that the physician’s order was never updated to reflect this current practice, resulting in a discrepancy between documented orders and actual care, and a failure to meet professional standards of practice.
A resident developed a right elbow wound after scraping it on a wheelchair wheel, and an LPN initially cleansed the area and applied a bandage. The wound was never documented in the medical record, and no wound assessment, provider or family notification, or wound care orders were completed. Days later, the resident was observed with a dressing falling off and dried blood, and reported the bandage had not been changed since the injury. The wound care nurse and DON confirmed they were unaware of the wound and that required processes for new wounds, including documentation and obtaining treatment orders, had not been followed.
A resident with chronic respiratory failure, COPD, and a tracheostomy had a physician’s order for an oxygen concentrator at 3 LPM, but surveyors twice observed the concentrator set at 4 LPM. The resident reported staff had increased the flow after a low oxygen saturation reading, yet there was no documentation of when the change occurred, no respiratory assessment supporting the adjustment, and no evidence that a provider was notified or new orders obtained. An LPN and the DON confirmed the lack of documentation and communication regarding the change in oxygen therapy.
A resident admitted to the facility did not receive routine dental services, including an annual oral exam and necessary dental care such as cleaning, fillings, or denture adjustments. The resident’s family member reported that the resident had not seen a dentist since admission and noted missing teeth. The resident confirmed she had not been to a dentist and stated she wanted to go. Social Services also confirmed that no dental visit had been arranged for the resident during her stay.
Surveyors found that two CNAs did not have any documented in‑service training hours in their employee files despite a facility expectation of at least 12 hours of annual in‑service education, including dementia care and abuse prevention. The administrator confirmed that there was no in‑service training documentation for these CNAs, resulting in a cited deficiency related to inadequate staff training to meet resident care needs.
Staff did not follow proper infection prevention protocols when a disposable isolation gown was left hanging in the hallway outside a room under COVID-19 precautions. An LPN confirmed the gown should have been discarded after use, and the DON stated that all PPE must be removed before exiting the resident's room. This failure occurred while a resident was isolated for COVID-19.
Surveyors observed that the kitchen griddle was missing all four control knobs, preventing proper adjustment of the gas burners. This issue was confirmed by the DM and affected the majority of residents who received meals from the kitchen.
The facility did not ensure resident privacy and confidentiality when a privacy curtain between two residents' beds remained off track for months, leaving a gap, and a paper towel with a resident's name and vital signs was left unattended in a hallway. Staff confirmed these lapses, and the DON acknowledged that protected methods should be used for recording resident information.
The facility did not update care plans for two residents to reflect current information, including a change in discharge plans for one resident and the addition of psychotropic medications for another. The care plans lacked necessary updates and interventions, as confirmed by the DON.
A resident with type 2 diabetes was found to have overgrown toenails and callused feet, with no evidence of toenail care or podiatry referral since admission. Staff confirmed that toenail care had not been provided and that a podiatrist was not available to the facility, resulting in a lack of appropriate foot care for the resident.
Staff failed to document required blood pressure and heart rate readings before administering certain medications to a resident with hypertension and atrial fibrillation, and entered an incorrect diagnosis on the medication administration record for another resident prescribed mirtazapine. The Director of Nursing confirmed these documentation errors, resulting in incomplete and inaccurate medical records.
A resident who needed partial to moderate assistance with personal hygiene was observed to have overgrown and jagged fingernails. The resident stated that staff had not offered to cut her fingernails and she did not have clippers to do it herself. A CNA confirmed the resident's fingernails had not been cut.
A facility failed to investigate an abuse allegation involving a deceased resident. RN #1 used the deceased resident in a prank on NA #1, who was instructed to take the resident's vitals as a joke. The facility did not recognize this as abuse, and the Administrator was unaware of the prank until informed by NA #1's family. The incident was not reported to the state, and RN #1 was not immediately removed from duty. The facility's lack of action resulted in an Immediate Jeopardy situation.
A facility failed to recognize the mistreatment of a deceased resident when an RN instructed an NA to take vital signs as part of a prank. The NA, upon discovering the resident was deceased, experienced a panic attack. The Administrator did not initially report the incident as mistreatment, believing it was a staff issue. The RN received a reprimand, but no corrective action was taken regarding the respect of deceased residents.
A facility failed to respect a resident's dignity when a nurse used the deceased resident to play a prank on a nursing assistant. The nurse instructed the assistant to take the vital signs of the deceased resident, causing distress. The incident was known to several staff members, and the administrator initially misunderstood it as a teaching opportunity. The resident's family expressed disgust over the disrespectful act.
The facility failed to provide timely written transfer notices for four residents who were hospitalized for various reasons, including falls, abnormal lab results, and altered mental status. The DON confirmed the absence of these notices, which should have been completed at the time of transfer or as soon as practicable.
The facility did not provide written notices of the bed hold policy to residents or their representatives during hospital transfers. This affected four residents who were transferred for various medical reasons, and their records lacked the required notices. The DON confirmed the absence of these notices and was unsure of the timing for providing them.
The facility failed to update care plans for three residents who refused certain care activities, such as showers, blood glucose checks, and teeth brushing. The care plans lacked documentation of these refusals and did not include interventions to address them, despite staff being aware of the issues.
The facility failed to provide adequate ADL assistance for three residents, particularly in oral care and bathing. One resident, requiring substantial assistance, missed several scheduled showers, with no documentation explaining the omissions. Another resident, dependent on staff for showers, was cooperative but still missed scheduled showers. A third resident, also dependent, received minimal showers and inconsistent oral care, with the DON confirming the lack of documentation and adherence to care schedules.
The facility failed to follow physician orders for two residents, one of whom was not weighed weekly as required, despite being underweight. Another resident did not receive insulin as prescribed, with missing blood glucose documentation and no notification to the physician when insulin was held. This lack of adherence to orders could have impacted the residents' health monitoring and management.
The facility failed to follow its policies on food handling, staff attire, and hand hygiene, affecting 56 residents. Observations revealed undated food items, improper use of beard covers and hair nets, and inadequate handwashing practices. Staff were seen performing tasks with the same gloves without washing hands, and incorrect handwashing techniques were demonstrated.
A facility failed to complete a resident's quarterly MDS assessment within the required timeframe. The resident, with conditions including hypertension and diabetes type II, had an overdue assessment that was not completed due to a lapse in the automatic scheduling system. The MDS Coordinator confirmed the assessment was past due by over 120 days.
A facility failed to complete and transmit a quarterly MDS assessment for a resident with hypertension and diabetes type II within the required timeframe. The assessment, due 92 days after the previous one, was delayed by 120 days. The MDS Coordinator confirmed the oversight, noting that assessments are scheduled automatically in the Point Click Care System.
A facility failed to update a resident's PASARR Level 1 Screening after new diagnoses of bipolar disorder and major depressive disorder were added. The Admissions Coordinator was unaware of the changes and relied on the DON for updates. PASARR personnel confirmed a re-screening was necessary.
A resident with dementia and unsteadiness experienced multiple falls, but the facility failed to update the care plan with preventative interventions. Despite documented falls and a decline in cognitive function, the care plan remained unchanged since August 2022. Facility policies required intervention adjustments, but these were not implemented.
The facility failed to maintain clean oxygen concentrator filters for two residents, one with heart failure and another with COPD, as observed during multiple inspections. The filters were found to be heavily debris-laden and dirty, contrary to the facility's policy requiring weekly cleaning. The DON and UM acknowledged the issue, indicating a lack of clarity on cleaning responsibilities.
The facility did not fill in the daily census on the GenSTAR Daily Nurse Staffing Form, which is posted in a conspicuous area. This omission was observed on multiple occasions, potentially causing uncertainty for visitors about the staff-to-resident ratio. The Administrator confirmed that the census should have been indicated on the form.
A facility failed to maintain complete and accurate medical records for a resident, as staff did not document meal intake over several days. Despite a CNA stating the resident had not eaten for a week, the records lacked documentation of this issue. The DON confirmed the absence of necessary documentation.
The facility failed to store and serve food under sanitary conditions for 77 residents. Six frozen hamburger patties were found sitting on top of a microwave without proper containment, and the Dietary Manager was observed not wearing a facial hair covering or hairnet. The DM confirmed these lapses in food safety practices.
The facility failed to report a resident's aggressive and threatening behavior, including an assault on a nurse, to the State Survey Agency within the required five-day period. The resident exhibited violent behavior, resulting in the nurse's injury and the resident's arrest, but the incidents were not reported as required.
The facility failed to revise the care plan for a resident to include a prescribed dysphagia advanced diet and did not include required interdisciplinary team members in care plan meetings for another resident. This could result in staff being unaware of changes in care and residents not receiving appropriate care.
The facility failed to provide necessary mental health services for a resident with dementia, depression, and anxiety, despite physician's orders. The resident exhibited aggressive behaviors, and staff interventions were limited to redirection. Interviews revealed a lack of awareness and documentation regarding the resident's mental health needs and the absence of available psychiatric services.
A facility failed to provide timely social services for a resident who requested to be transferred closer to his wife. Despite multiple requests and family agreement, the first documented referral was made months later, and the facility's Social Service Director could not specify other facilities contacted. The resident's medical record lacked documentation of other referral attempts.
A resident was prescribed Risperidone without a documented psychiatric diagnosis to justify its use. The DON confirmed that the psychiatric evaluation did not document a diagnosis of psychosis, and the resident's medical record lacked the necessary documentation to support the administration of the antipsychotic medication.
A facility failed to provide a complete discharge summary for a resident, missing critical information such as dietary recommendations, skin condition, infections, hearing and vision abilities, dental concerns, speech pattern, continence, assistance levels, signs of condition changes, therapy services, medication reconciliation, and education provided. The form was also not signed off by staff. The DON confirmed these deficiencies and the expectations for staff.
The facility failed to ensure staff received appropriate behavioral health training, resulting in inadequate care for a resident with significant behavioral health concerns. The resident exhibited aggressive behaviors, including threats and physical assault, but staff were not trained to manage these issues effectively.
A resident with a physician's order for a dysphagia advanced texture diet was served whole chicken nuggets and French fries instead of the required bite-sized, moist foods. This discrepancy was confirmed by both a CNA and the DON.
The facility failed to keep treatment carts locked when not supervised by staff, affecting all 61 residents on the 100 and 200 Units. Observations revealed unlocked and open treatment carts containing hydrocortisone lotions, scissors, and lancets, with no staff present. This was confirmed by an LPN, the Unit Manager, and the Administrator.
Improper Labeling and Storage of Food Items in Kitchen and Pantry
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices affecting all 64 residents who receive meals from the kitchen, when observations showed multiple food items in the walk-in refrigerator, freezer, and pantry were not stored under sanitary conditions. In the walk-in refrigerator, surveyors observed two butter blocks without dates, a large uncovered container of Jello with no date, chorizo dated 12/20/25, pears in a container with no date, a peanut butter bar dessert in a container with no date, and sliced ham in an open ziplock bag dated 01/01/25. In the pantry storage area, baked crispy pineapple cake was found with no date. In the walk-in freezer, surveyors observed opened Salsbury steak, chicken patties, lemon meringue pie, and pie crusts all without dates, and corn tortillas that were loosely opened, not tightly sealed, and dated 12/11/25. During an interview, the Dietary Manager stated that she checks food dates daily and that staff who unload the food truck are supposed to date boxes before storing them and date food when it is opened. She confirmed that there were items in the refrigerator and freezer with no dates, no covers on some food containers, food that was not tightly sealed, and food with outdated dates, and stated that her expectation is that staff date and mark foods and discard them when outdated.
Failure to Update Care Plans With Current Orders and Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans to reflect current physician orders and resident conditions for multiple residents. One resident had a physician’s order dated 12/31/25 for enteral feeding with 250 ml of Jevity 1.2 to be given when oral intake was less than 25% of meals, but the comprehensive care plan dated 04/22/25 did not include this enteral feeding order or related interventions. The DON confirmed that the resident’s enteral feeds and interventions were not documented in the care plan. Another resident, admitted on an unspecified date, was observed on 01/06/26 to have thick, layered toenails. This resident had a physician’s order dated 11/14/25 to check fingernails and toenails, trim and file as allowed every Tuesday and Friday, and document refusals. However, the care plan dated 12/28/25 did not include the nail care order or describe how staff manage care when the resident refuses nail care and becomes combative. A CNA reported that this resident does not allow staff to file or trim her nails and becomes combative, and the Unit Manager stated his expectation that the resident should be care planned for nail care and behaviors. A third resident had a physician’s order dated 12/29/25 for PRN oxygen therapy at 1–2 L/min via nasal cannula for low oxygen, but the care plan dated 09/08/25 did not include oxygen therapy or related interventions. The Administrator confirmed that the resident’s oxygen and interventions were not documented on the care plan and stated that oxygen should be documented there. Across these residents, surveyors identified that the facility did not ensure care plans were revised with the most current information, including new physician orders and behavioral responses to care, despite observations, record reviews, and staff interviews confirming the omissions.
Failure to Complete Required Performance Evaluations for CNAs
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to complete required performance reviews for certified nurse aides (CNAs). Record review of employee files showed that CNA #16, hired on 11/18/24, had no performance evaluations documented in the file. Similarly, CNA #17, hired on 09/20/24, also had no performance evaluations documented. During an interview on 01/13/26 at 9:27 AM, the administrator confirmed that there were no performance evaluations for CNA #16 and CNA #17 and acknowledged that performance evaluations were expected to be completed at least annually for CNAs. The report states that this deficient practice could likely result in staff being undertrained and providing inadequate care.
Lack of Physician Documentation of Benefit/Risk Analysis for Psychotropic and Antidepressant Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultant pharmacist recommendations regarding psychotropic and other medications were reviewed and acted upon by the prescribing physicians, including documentation of a resident-specific benefit/risk analysis or rationale when recommendations were not followed. For multiple residents receiving atypical antipsychotics or antidepressants, the pharmacy recommendation summary reports documented concerns and specific recommendations, but the medical records did not contain corresponding physician documentation explaining the clinical reasoning for continuing the medications or declining gradual dose reduction (GDR). The facility’s policies required a licensed pharmacist to perform monthly drug regimen reviews and for irregularities to be addressed, but the surveyors found that this process was not completed as required at the physician documentation level. For one resident with vascular dementia, unspecified dementia, anxiety disorder, and insomnia, the physician had ordered quetiapine 200 mg at bedtime for dementia with psychotic disturbance. The pharmacy recommendation summary noted that the resident was receiving quetiapine for dementia-related psychosis and included information that patients with dementia-related psychosis treated with atypical antipsychotics have an increased risk of death and cerebrovascular adverse events compared to placebo. The pharmacist’s review stated that a benefit/risk analysis warranted continuation at the present dose, but the physician did not provide a benefit/risk analysis with patient-specific information in the medical record explaining why the resident needed to remain on the medication. For another resident with Alzheimer’s disease and dementia with behavioral disturbance, the physician had ordered quetiapine 25 mg twice daily for dementia with psychotic disturbance. The pharmacy recommendation summary similarly documented that the resident was receiving quetiapine for dementia-related psychosis and reiterated the increased risk of death and cerebrovascular adverse events associated with atypical antipsychotics in this population. The pharmacist again concluded that a benefit/risk analysis supported continuation at the current dose, yet the physician did not document a resident-specific benefit/risk analysis in the chart to justify ongoing use. A third resident with dementia and agitation had a physician’s order for Rexulti 1.5 mg once daily, later documented in the pharmacy recommendation summary as Rexulti 2 mg once daily in the evening for dementia with behavioral disturbance and agitation. The pharmacy report included the same warning about increased mortality and cerebrovascular events in elderly patients with dementia-related psychosis treated with atypical antipsychotics and stated that a benefit/risk analysis supported continuation at the present dose. However, the physician did not document a benefit/risk analysis with patient-specific information in the resident’s medical record. During an interview, the DON acknowledged that she did not see documentation in the charts specifically addressing benefit/risk analysis for these medications and stated that her expectation was that the physician would document this analysis. For a fourth resident diagnosed with depression, unspecified dementia without behavioral or psychotic disturbance, and anxiety disorder, the physician had ordered escitalopram 15 mg daily for depression and Zyprexa 5 mg daily at bedtime for dementia with psychotic disturbances. A pharmacy recommendation summary noted that the resident was receiving Zyprexa for dementia with psychotic disturbance and recommended consideration of GDR, again citing the increased risk of death and cerebrovascular adverse events in elderly patients with dementia-related psychosis treated with atypical antipsychotics. The pharmacist’s review stated that a benefit/risk analysis warranted continuation at the present dose, but the physician did not provide a resident-specific benefit/risk analysis in the record. A later pharmacy recommendation summary for the same resident indicated that escitalopram 15 mg daily was being given and recommended consideration of GDR; the physician did not provide a rationale with patient-specific information as to why a GDR was not done. In an interview, the DON confirmed that a rationale and benefit/risk analysis were not documented in this resident’s medical record and reiterated that her expectation was that such documentation should be present.
Inaccurate Dental, Activity, and Skin Documentation in Resident Records
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for multiple residents. One resident’s admission assessment, dated 11/17/25, documented that the resident had no natural teeth or tooth fragments and was edentulous, while direct observation and interview showed the resident had several broken, discolored teeth that needed to be pulled. An LPN and the DON later confirmed that the resident was not edentulous and that the admission assessment was inaccurate, despite the expectation that staff accurately assess and document dental status. Additional documentation inaccuracies were identified in activity and skin records. For one resident, a family member reported the resident wanted to attend Christian church services and was told Catholic services were available, but the activities participation records from October to December 2025 contained no documentation of church attendance, even though the unit manager and activities director stated the resident was taken off the secure unit for church. Another resident’s care plan called for encouragement to participate in activities and provision of one-to-one programs as needed, yet the activities participation records for the same period showed no one-to-one activities documented, despite the unit manager stating these occurred at least daily. A further resident was observed with a bleeding right elbow wound that was bandaged by an LPN, and later with a dressing that was falling off and appeared unchanged since the injury; however, a skin assessment dated 01/08/26 documented no skin issues. The wound care nurse and DON confirmed the presence of the wound and that the skin assessment was inaccurate, despite expectations for at least weekly, accurate skin assessments.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the resident’s call light was within reach. During an observation of the resident’s room, the surveyor noted that the resident’s call light was hanging over the light fixture above the bed, approximately six feet from the floor, making it inaccessible to the resident. In an interview, CNA #8 confirmed that the call light was hanging from the light fixture and that the resident could not reach it. In a separate interview, the Administrator acknowledged that residents should be able to reach their call lights. These observations and interviews show that the facility did not ensure the resident’s call light was positioned so the resident could use it, resulting in a failure to provide reasonable accommodation for the resident’s need to summon assistance.
Inaccurate MDS Assessments for Dental Status and Vascular Diagnoses
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, admission documentation showed she was admitted on an unspecified date, and during observation and interview she reported having several broken teeth that needed to be pulled. The surveyor observed broken teeth and discoloration of the upper and lower mouth. However, the resident’s admission MDS assessment documented that she was edentulous (lacking teeth). An LPN later observed the resident and confirmed she was not edentulous, and the DON acknowledged that the admission MDS inaccurately documented the resident as edentulous and that staff were expected to ensure MDS assessments were accurate. For another resident with a diagnosis of unspecified cerebral infarction, medical record review showed a CTA of the neck revealed complete occlusion of the right common carotid artery and greater than 70% stenosis of the left proximal internal carotid artery, with a recommendation for neurovascular evaluation. A provider progress note documented diagnoses of stenosis of the left internal carotid artery and occlusion of the right internal carotid artery, and that these serious findings and associated risks were discussed with the resident. Despite these documented diagnoses, the resident’s subsequent Quarterly MDS assessment did not include the CTA-related diagnoses in Section I (active diagnoses). The MDS coordinator stated she was unaware of these diagnoses, explained that the medical team liaison usually notifies her of new diagnoses, and acknowledged that the CTA findings should have been added to the resident’s MDS.
Failure to Update Enteral Feeding Order to Reflect Current Practice
Penalty
Summary
The facility failed to meet professional standards of practice by not updating a physician’s order for a resident’s enteral feeding regimen. Record review showed an active order dated 11/08/25 for Jevity 1.2 via PEG tube four times a day, and a subsequent order dated 12/01/25 for a regular/liberalized pureed diet with nectar-thick liquids, allowing sandwiches and soft snacks with supervision. During interview, one LPN stated that the resident only receives Jevity through the PEG tube when oral intake is less than 50% of meals, while another LPN reported that the resident no longer receives PEG tube feedings and is eating 100% of meals by mouth and has been doing so for a long time. The nurse practitioner confirmed that the resident is currently eating by mouth and acknowledged that the existing order for PEG tube feeding four times a day had not been updated to reflect the current practice of administering PEG feeding only if the resident consumes less than 50% of the meal orally. The DON also confirmed that the order had not been updated and stated that it should specify that PEG feeding is to be used only when the resident eats less than half of the meal by mouth. This discrepancy between the written physician’s order and the care actually being provided led to the deficiency related to professional standards of quality.
Failure to Assess, Document, and Treat a New Elbow Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate treatment and care for a resident’s right elbow wound. The resident was admitted on an unspecified date, and on 01/05/26 was observed near the nurses’ station with blood on the right elbow. An LPN cleansed the elbow and applied a bandage, stating the resident had scraped the elbow on the wheel of his wheelchair. However, there was no documentation in the medical record that the resident had a wound on the right elbow, that a dressing had been placed, or that any wound assessment had been completed. On 01/08/26, the resident was observed in the hallway with a dressing that was falling off the right elbow and appeared to have dried blood. The resident stated staff had not changed the bandage since the wound occurred on 01/05/26. The wound care nurse reported she was not aware the resident had a right elbow wound until that observation and confirmed the presence of the wound and deteriorating dressing. She stated that when a new wound is identified, staff are expected to assess the wound, notify the provider and family, document the wound and notifications in the medical record, and enter wound care orders. She confirmed there was no documentation of the wound, no evidence the provider was notified, and no wound care orders in the record. The DON similarly confirmed that staff are expected to evaluate and clean new wounds, notify the provider and family, and enter wound care orders, and acknowledged that staff did not document the wound, notify the provider or family, or enter any wound care orders for this resident’s right elbow wound.
Failure to Follow Oxygen Orders and Document Respiratory Status Change
Penalty
Summary
The deficiency involves staff failing to follow a physician’s order for oxygen therapy and failing to document a change in respiratory care for one resident. The resident had chronic respiratory failure with hypoxia, COPD, and a tracheostomy, and had a physician’s order for an oxygen concentrator set at 3 LPM on all shifts. During observation, the resident’s oxygen concentrator was found set at 4 LPM, and the resident reported that staff had increased the flow from 3 LPM to 4 LPM a couple of days earlier when his oxygen saturation was 72%. A subsequent observation again confirmed the concentrator remained at 4 LPM. Record review showed no documentation of when the oxygen flow was increased, no respiratory assessment to support the change, and no evidence that the provider was notified or that new orders were obtained. An LPN confirmed the discrepancy between the ordered 3 LPM and the observed 4 LPM setting and acknowledged there was no documentation explaining the change or provider notification. The DON stated that staff were expected to document an assessment, notify the provider and family, and obtain new orders when a resident’s respiratory status changed and oxygen concentration was adjusted, but confirmed that none of this was documented for this resident, and there were no messages in the communication application regarding a change in respiratory status or the need to increase oxygen concentration.
Failure to Ensure Routine Dental Services for a Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental services, including an annual inspection of the mouth and necessary dental care such as cleaning, fillings, or denture adjustments, as required. The resident was admitted on 04/10/25, and record review and interviews confirmed that no dental visit had occurred since admission. During an interview, the resident’s family member stated that the resident had not seen a dentist while at the facility and noted that the resident had missing teeth. In a separate interview, the resident reported that she had not been to the dentist and expressed a desire to go. Social Services confirmed that the resident had not been seen by a dentist since admission. This deficient practice was identified as likely to cause the resident unnecessary pain, embarrassment over the condition and appearance of her teeth, and potential dental or oral complications. The deficiency centers on the facility’s inaction in arranging or providing access to dental services for the resident after admission, despite the resident’s missing teeth and expressed wish to see a dentist, and confirmation from Social Services that no dental visit had been facilitated during her stay.
Failure to Provide Required Annual In‑Service Training for CNAs
Penalty
Summary
The facility failed to ensure that CNAs received the required 12 hours of annual in‑service training, including dementia care and abuse prevention, as identified through record review and staff interview. Review of employee files showed that one CNA hired on 11/18/24 and another CNA hired on 09/20/24 had no documentation of any in‑service trainings in their personnel files. During an interview on 01/13/26 at 9:27 AM, the administrator confirmed that there was no documentation of in‑service trainings for these two CNAs and acknowledged that CNAs were expected to complete at least 12 hours of in‑service training annually. This lack of documented training was cited as a deficiency because it was likely to result in CNAs not receiving the necessary training to meet residents’ care needs. No specific residents, medical histories, or clinical conditions were mentioned in the report in connection with this deficiency.
Failure to Follow Transmission-Based Precautions for COVID-19
Penalty
Summary
Staff failed to maintain proper infection prevention and control measures for a resident diagnosed with COVID-19. During an observation, a yellow disposable isolation gown was found hanging on a hallway rail outside the resident's room, which was under droplet/COVID precautions. The posted sign indicated that staff should wear an N95 mask, gown, and face shield or goggles to enter the room. According to interviews, the expectation was that personal protective equipment (PPE), including gowns, should be disposed of after use and not left exposed in the hallway. An LPN confirmed that the gown should have been discarded in a bin after use, and the DON stated that all PPE must be worn inside the resident's room and removed before exiting to the main hall. The resident had been isolated to their room for 14 days following a positive COVID-19 diagnosis upon return from the hospital. The failure to properly dispose of the isolation gown and adhere to transmission-based precautions constituted a breach in the facility's infection control program.
Failure to Maintain Safe Operating Condition of Kitchen Griddle
Penalty
Summary
The facility failed to ensure that essential kitchen equipment, specifically the griddle, was maintained in safe operating condition. During an observation of the kitchen, it was noted that all four knobs on the gas griddle were missing, making it impossible to properly control the gas burners. This deficiency affected 69 out of 72 residents who consumed food prepared in the kitchen, as identified by the resident matrix provided by the Administrator. The absence of the knobs was confirmed by the Dietary Manager during an interview.
Failure to Safeguard Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information for three residents. In one instance, the privacy curtain between two residents' beds was observed to be off track, leaving a gap at the top and preventing it from being fully closed. Both a nurse aide and an LPN confirmed that the curtain had been in this condition for several months, compromising the residents' ability to have private space during care or personal activities. Additionally, a paper towel containing a resident's name and vital signs was found left unattended on a wheelchair in the hallway outside the resident's room, with no staff present. An LPN acknowledged that this information should not have been exposed in a public area, and the Director of Nursing confirmed that resident information should not be written on a paper towel and that a protected vital sheet is the appropriate method for recording such data.
Failure to Update Care Plans with Current Resident Information and Medication Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information for two residents. For one resident, documentation showed that the resident expressed a desire to be discharged to an assisted living facility, and this was discussed with the guardian and during a care plan meeting. However, the resident's care plan continued to state that discharge was not expected and did not reflect the updated discharge plan or the resident's expressed wishes. For another resident, physician orders were in place for two psychotropic medications, trazodone and mirtazapine, prescribed for circadian rhythm disorder and depression, respectively. Despite these orders, the resident's care plan did not include any interventions or goals related to the use of these medications. The DON confirmed that the care plan lacked the required information for these medications and acknowledged that interventions and goals should have been included.
Failure to Provide Foot Care for Diabetic Resident
Penalty
Summary
Staff failed to provide appropriate foot care for a resident with type 2 diabetes mellitus. The resident was admitted with this diagnosis and, during observation, was found to have overgrown toenails and callused feet. The resident reported that staff had not offered to cut her toenails and that she had not seen a podiatrist since admission. Additionally, the resident stated she had lost a toenail, which was documented in a progress note, and was instructed to cleanse and dress the area until healed. Interviews with facility staff confirmed that the resident's toenails were long and had not been cut. Staff also acknowledged that the facility did not have a podiatrist available to provide foot care, and no referrals had been made for the resident to see a podiatrist until recently. Nursing staff indicated that residents' nails should be checked weekly, but this had not occurred for the resident in question.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
Staff failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses of hypertension and paroxysmal atrial fibrillation, physician orders required blood pressure and heart rate monitoring prior to administering medications such as metoprolol, lisinopril, and furosemide. However, staff did not document the required blood pressure or heart rate readings on the medication administration record (MAR) or in the vital signs section of the medical record on multiple occasions throughout August. The Director of Nursing confirmed that staff are expected to document these vital signs as indicated in the physician's orders, either on the MAR or in the vital signs section. For another resident admitted with a diagnosis of circadian rhythm sleep disorder, the MAR incorrectly listed the indication for mirtazapine as depression, while the psychiatric provider's note and the Director of Nursing confirmed the medication was prescribed for circadian rhythm disorder. The DON acknowledged that staff entered the order with the wrong indication. These documentation errors resulted in incomplete and inaccurate medical records for both residents.
Failure to Assist with Personal Hygiene—Fingernail Care
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required partial to moderate help with personal hygiene. Record review showed the resident was admitted to the facility and required assistance, as documented in the most recent MDS assessment. During an observation, the resident's fingernails were found to be overgrown, jagged, and uneven from breaking off. The resident reported that staff had not offered to cut her fingernails and that she did not have clippers to do it herself. A CNA confirmed that the resident's fingernails were long and had not been cut.
Failure to Investigate Abuse Allegation Involving Deceased Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse/mistreatment involving a deceased resident. The incident involved a staff member, RN #1, who used the deceased resident to play a prank on another staff member, NA #1. RN #1 instructed NA #1 to take the vital signs of the deceased resident, which was intended as a joke. This action was not identified as abuse or mistreatment by the facility, and the incident was not reported to the state as required. The facility did not conduct a thorough investigation into the incident. The Administrator, who is the abuse coordinator, was not aware of the prank aspect of the incident until receiving an email from NA #1's family member. The investigation was initially focused on improper postmortem care rather than the mistreatment of the resident. RN #1 was not immediately removed from duty, and there was no documentation of reprimand for disrespecting the deceased resident. Additionally, there was no education provided to staff regarding the respect and dignity of deceased residents. The facility's failure to recognize and address the incident as abuse/mistreatment resulted in an Immediate Jeopardy situation. The facility's Abuse Prohibition Policy requires immediate reporting and removal of staff involved in alleged abuse, which was not followed in this case. The lack of immediate corrective action and staff education put residents at risk of similar mistreatment.
Failure to Recognize Mistreatment of Deceased Resident
Penalty
Summary
The facility failed to maintain the highest practicable well-being of a resident, identified as R #16, when the administration did not recognize the mistreatment and disrespect shown to the resident after her death. The incident involved RN #1 instructing NA #1 to take the vital signs of R #16, who had already passed away, as part of a prank on another staff member. NA #1, upon discovering the resident was deceased, was distraught and required emergency medical services due to a panic attack. The administration did not initially recognize the incident as mistreatment, and it was not reported to the state as a staff-to-resident incident. The Administrator, who is also the Abuse Coordinator, led the investigation but did not acknowledge the prank as inappropriate or recognize the mistreatment of the deceased resident. The Administrator believed the incident was a staff issue and did not report it to the state. It was only after receiving an email from NA #1's family member that the Administrator initiated an investigation. The investigation revealed that RN #1 had used the situation as a teaching opportunity, and no corrective action or education was provided to RN #1 or other staff regarding the respect of deceased residents. The facility's investigation report lacked documentation of the Director of Nursing's involvement or oversight of RN #1 and other nursing staff involved. RN #1 received a written reprimand for sending NA #1 to take vitals on a deceased resident, but there was no reprimand related to the mistreatment of the deceased resident. The facility's failure to recognize and address the mistreatment of a deceased resident resulted in an Immediate Jeopardy situation, which was later addressed through a plan of removal.
Disrespectful Prank Involving Deceased Resident
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and respect when a staff member used the deceased resident to play a prank on another staff member. The incident involved a resident who was admitted to the facility and had a full code status, indicating they wished to receive all possible life-saving measures. After the resident passed away, a nurse instructed a nursing assistant to take the deceased resident's vital signs as part of a prank, without the consent of the resident or their family. This action was disrespectful and dehumanizing to the deceased resident and their family. Multiple staff members, including nursing assistants and the unit manager, were aware of the prank, and some did not attempt to prevent it. The administrator was informed of the incident and initially believed it was intended as a teaching opportunity rather than a joke. However, a family member of the nursing assistant later clarified that it was indeed a prank. The deceased resident's son expressed that his mother would have been horrified by the incident, describing it as disgusting. The nurse involved in the prank did not respond to attempts to contact them for an interview.
Failure to Provide Timely Transfer Notices
Penalty
Summary
The facility failed to provide timely written notices of transfer to residents, their representatives, and the Ombudsman for four residents who were hospitalized. Resident #8 was transferred to the hospital twice, once for a fall and once for evaluation of an abdominal wound and fever, but no written transfer notices were documented. Resident #9 was sent to the hospital due to abnormal lab results, and Resident #11 was hospitalized following a fall, both without written transfer notices. Similarly, Resident #13 was sent to the hospital for altered mental status, and no written transfer notice was recorded. During an interview, the Director of Nursing confirmed the absence of transfer notices for these residents, acknowledging that such notices should be completed at the time of transfer or as soon as practicable.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written notices of the bed hold policy to residents or their representatives, which specifies the duration the bed would be held during hospital transfers or therapeutic leave. This deficiency was identified for four residents who were transferred to the hospital for various medical reasons, including falls, evaluation of an abdominal wound and fever, abnormal lab results, and a change in mental status. Upon review of the medical records for these residents, it was found that none contained the required written notice of the bed hold policy. During an interview, the Director of Nursing (DON) confirmed the absence of these notices and was unable to recall when the bed hold should be provided to the residents.
Failure to Update Care Plans for Resident Refusals
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, leading to deficiencies in the care provided. Resident #1, who was admitted with a need for assistance with personal care, had a history of refusing showers. However, the care plan did not include any interventions to assist or encourage the resident when she refused to shower. Similarly, Resident #14, diagnosed with type 2 diabetes mellitus, refused blood glucose checks and insulin, believing she was cured. The care plan for this resident did not document her noncompliance or include interventions for her refusals, despite the Director of Nursing being aware of the situation. Resident #17, also admitted with a need for assistance with personal care, was noted to refuse having his teeth brushed at times. The care plan for this resident lacked documentation of his refusals and did not outline any interventions to assist or encourage him. The Director of Nursing confirmed that the refusals were not documented and that interventions should have been included in the care plan. These oversights in updating care plans with current resident information could result in staff being unaware of changes in care needs and residents not receiving appropriate care.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, specifically in the areas of oral care and bathing. Resident #1, who required substantial assistance for showers, was not consistently offered or given showers according to the facility's schedule. Documentation showed that Resident #1 received only four out of nine scheduled showers in December and four out of six in January. Additionally, there was no documentation explaining why showers were missed on specific days. Resident #1's family member confirmed that the resident was not showered on scheduled days, and a CNA noted that if Resident #1 refused a shower, it was not offered again until the next scheduled day unless requested by the resident. Resident #2, who was dependent on staff for showers, was also not consistently provided with scheduled showers, receiving only three out of nine in December and four out of six in January. The CNA confirmed that Resident #2 was cooperative and did not refuse showers, yet no explanation was provided for the missed showers. Resident #17, also dependent on staff for showers, received only one out of nine scheduled showers in December and two out of six in January. The DON confirmed the lack of documentation for missed showers and noted that Resident #17 should receive two showers per week. Additionally, Resident #17's oral care was neglected, with teeth brushed only a few times during the day shift, despite the expectation of twice-daily brushing. The DON acknowledged the inconsistency in oral care documentation, particularly during the day shift.
Failure to Follow Physician Orders for Weighing and Insulin Administration
Penalty
Summary
The facility failed to ensure that staff followed physician's orders for two residents, leading to potential risks in their care. For one resident, the facility did not adhere to the physician's order to weigh the resident weekly, as evidenced by the weight log showing missed weigh-ins over several months. This resident, who was underweight and had a low BMI, was only weighed sporadically, which could have hindered the monitoring of their nutritional status and overall health. For another resident, the facility did not follow the physician's orders regarding insulin administration. The resident's medical records showed multiple instances where blood glucose levels were not documented, and insulin was not administered as prescribed. Additionally, there was no documentation that the physician was notified when insulin was held or when the resident was noncompliant with blood glucose checks and insulin administration. This lack of communication and documentation could have led to unawareness of changes in the resident's condition.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its own policies regarding food handling, staff attire, and hand hygiene, which had the potential to affect 56 residents consuming food prepared by the facility's kitchen. During an initial tour of the kitchen, it was observed that a gallon jug of milk was open without an open date, contrary to the facility's policy that requires dating of food items once opened. Additionally, several spices were found on the shelf without open dates, indicating a lapse in following the established food handling procedures. Staff attire and hygiene practices were also found to be lacking. Dietary staff were observed not wearing beard covers or hair nets as required by the facility's policy. One staff member was seen making burritos without a beard cover, and another walked through the kitchen without a hair net while carrying personal belongings. The Dietary Manager was observed with a beard cover under his chin, not properly covering his facial hair, which was acknowledged as inappropriate by the staff during interviews. Hand hygiene practices were not consistently followed, as observed during multiple instances where staff failed to wash hands between glove changes or after touching potentially contaminated surfaces. Staff were seen performing various tasks with the same pair of gloves, such as handling food, touching trash can lids, and retrieving items from different areas, without changing gloves or washing hands in between. The Dietary Manager and other staff demonstrated incorrect handwashing techniques, such as turning off faucets with elbows and touching trash can lids, which contradicted the facility's handwashing policy that requires using a paper towel to turn off the faucet and ensuring hands are not recontaminated.
Failure to Complete Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment was successfully transmitted and accepted within the required time frame. According to the October 2023 Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous assessment. However, the quarterly MDS assessment for a resident with medical diagnoses including hypertension and diabetes type II, with an Assessment Reference Date (ARD) of 07/23/24, was not completed. The MDS Coordinator confirmed that the assessment was past due by more than 120 days, indicating a lapse in the facility's adherence to the automatic scheduling system on the Point Click Care System.
Failure to Complete and Transmit Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment for a resident was successfully transmitted and accepted within the required timeframe. According to the Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous assessment. However, the quarterly MDS assessment for a resident, who was admitted with medical diagnoses including hypertension and diabetes type II, was not completed within this timeframe. The resident's annual MDS assessment with an Assessment Reference Date (ARD) of January 21, 2024, was accepted, as was the quarterly MDS with an ARD of April 22, 2024. However, the subsequent quarterly MDS assessment, which should have had an ARD of July 23, 2024, was not completed, resulting in a delay of 120 days past the due date. During an interview, the MDS Coordinator confirmed that the MDS assessments are scheduled automatically in the Point Click Care System. The coordinator acknowledged that the quarterly assessment for the resident was not completed as required, confirming the deficiency. This oversight indicates a failure in the facility's process to ensure timely completion and transmission of MDS assessments, as mandated by the RAI Manual guidelines.
Failure to Update PASARR After New Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed after a new diagnosis for a resident. The resident was admitted and re-admitted with diagnoses of anxiety, bipolar disorder, and major depressive disorder. The PASARR Level 1 Screening Form included the diagnosis of anxiety but did not reflect the new diagnoses of bipolar disorder and major depressive disorder. During an interview, the Admissions Coordinator stated she was unaware of the changes in the resident's diagnosis and relied on the Director of Nurses to inform her if a PASARR needed to be completed. The New Mexico PASARR personnel confirmed that a re-screening should have been conducted following the addition of the new diagnoses.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced multiple falls, which was identified during a review of records, interviews, and policy reviews. The resident, who had diagnoses including dementia, weakness, and unsteadiness on feet, was admitted to the facility and had a history of falls. Despite these incidents, the care plan was not updated with new interventions to prevent future falls. The resident's quarterly Minimum Data Set (MDS) assessments indicated a decline in cognitive function and recorded falls, yet the care plan remained unchanged since August 2022. The facility's incident reports and progress notes documented several falls, including an unwitnessed fall from a wheelchair and a fall while walking, but no preventative interventions were added to the care plan. Interviews with the Director of Nursing confirmed that the care plan had not been updated with new interventions after each fall. The facility's policies on falls management and accidents/incidents required the implementation of interventions to reduce risk and minimize injury, as well as adjustments to individualized intervention strategies as patient conditions change. However, these policies were not followed, as evidenced by the lack of updates to the resident's care plan despite multiple falls and changes in the resident's condition.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain clean oxygen concentrator filters for two residents, leading to a potential risk of infection and unnecessary respiratory treatment. Resident 29, diagnosed with heart failure, was observed to have a heavily debris-laden and dirty oxygen filter on their concentrator during multiple observations. The facility's policy required weekly cleaning of these filters, but this was not adhered to, as confirmed by the Unit Manager and the Director of Nursing during an interview. They acknowledged the filter's condition was unacceptable and identified a lack of clarity regarding the responsibility for cleaning the filters, with conflicting statements about whether it was the duty of certified nursing aides or nurses. Similarly, Resident 43, who had diagnoses of chronic obstructive pulmonary disease and shortness of breath, was also found to have dirty oxygen concentrator filters during observations. The Director of Nursing confirmed that the filters needed cleaning, indicating a failure to follow the facility's policy for maintaining respiratory equipment. This oversight in maintaining clean equipment for both residents highlights a deficiency in the facility's adherence to its own policies, potentially compromising the residents' respiratory health.
Failure to Indicate Daily Census on Nurse Staffing Form
Penalty
Summary
The facility failed to indicate the daily census on the GenSTAR Daily Nurse Staffing Form, which is posted daily in a conspicuous area. This omission was observed on multiple occasions, specifically on 09/17/24 and 09/18/24, where the form lacked the required resident census information. The absence of this information could lead to uncertainty for resident family, friends, or other visitors regarding the ratio of nursing staff to residents. During an interview on 09/19/24, the Administrator confirmed that the daily census should have been filled in on the form to inform visitors about the staff-to-resident ratio.
Incomplete Medical Records for Resident's Meal Intake
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one of the residents reviewed for abuse. Specifically, the facility did not document the meal intake for a resident over several days, despite a CNA stating that the resident had not eaten breakfast or lunch for a week. The CNA reported that she had documented the resident's lack of eating, but the records did not reflect this information. Upon review, it was found that there were multiple instances where staff did not document the amount of meal intake for the resident on various dates and times. Additionally, the resident's medical record lacked any documentation indicating that the resident was not eating. The Director of Nursing confirmed that the CNA did not document the resident's lack of eating, which should have been recorded.
Sanitary Food Handling and Storage Deficiency
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 77 residents. During an observation of the kitchen, six frozen hamburger patties were found sitting on top of a microwave without being in a wrapper, on a plate, or in a container. Additionally, the Dietary Manager (DM) was observed not wearing a facial hair covering for his moustache and not wearing a hairnet. The DM confirmed that the hamburger patties should not be left out without proper containment and acknowledged that hair should be covered in the kitchen.
Failure to Report Resident Abuse and Assault to State Agency
Penalty
Summary
The facility failed to report an incident of abuse to the State Survey Agency within the required five-day period. The incident involved a resident who exhibited aggressive and threatening behavior towards staff and other residents. The resident made violent threats, threw objects, and ultimately assaulted a nurse, resulting in visible injuries and the resident's arrest. Despite these serious events, the facility did not report the incidents to the State Agency, as the corporate quality clinical nurse deemed it unnecessary since the assault was on a staff member. The Director of Nursing and the Administrator confirmed that no reports were made to the State Agency regarding the resident's threats, aggressive actions, or the assault on the nurse. The resident in question had a history of aggressive behavior, including making threats to staff and other residents, throwing objects, and attempting to obtain cigarettes with sticks. The resident's actions escalated to physical violence when they threw silverware at a nurse, causing reddened marks on her face and neck. The nurse called the police, who arrested the resident for battery against a medical professional. Despite the severity of the incidents, the facility did not document the duration of the one-to-one observation for the resident and failed to report the incidents to the State Agency, as required by regulations.
Failure to Revise Care Plans and Include Interdisciplinary Team Members
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to potential gaps in care. For one resident, the care plan did not include the prescribed dysphagia advanced diet, despite a speech therapy evaluation and a medical order indicating the need for a regular/liberalized diet with moist foods in bite-sized pieces. This omission was confirmed by the Director of Nursing (DON) during an interview. The resident's care plan was not updated to reflect the necessary dietary adjustments, which could result in staff being unaware of the resident's specific dietary needs. For another resident, the care plan meetings did not include the required interdisciplinary team members. The meetings were attended by the MDS coordinator, the Social Services Director (SSD), and the Activities Director, but did not include nurses, CNAs, or the resident's provider. The MDS coordinator confirmed that she schedules the meetings and gathers information from the MDS assessment, which only covers a 7-day look-back period and does not provide a comprehensive view of the resident's condition. This lack of comprehensive input could lead to incomplete care plans that do not fully address the resident's needs.
Failure to Provide Mental Health Services
Penalty
Summary
The facility failed to provide necessary mental health services for a resident with a diagnosis of dementia, depression, and anxiety. Despite the physician's orders for psychiatric evaluation and treatment through Medi-tele care, the resident did not receive any mental or behavioral health services. The resident exhibited aggressive behaviors, such as throwing objects at staff and other residents, attempting to leave the facility, and making threats. The staff's interventions were limited to redirecting the resident and removing overstimulating items, but no formal mental health services were provided. Interviews with the Director of Nursing (DON), Medical Director, and Administrator revealed a lack of awareness and documentation regarding the resident's mental health needs and the absence of available psychiatric services. The DON confirmed that Medi-tele care had stopped providing services the previous year, and there were no alternative behavioral health services available in the community. The Medical Director did not recall being notified about the resident's behaviors, and the Administrator did not take the resident's threats seriously. No referrals were made to behavioral health hospitals, and the facility did not have any behavioral health services in place.
Failure to Provide Timely Social Services for Resident Transfer Request
Penalty
Summary
The facility failed to provide timely social services for a resident who requested to be transferred to another long-term care facility closer to his wife. The resident expressed his desire to move multiple times, starting from June 5, 2023, but the facility did not act promptly. Despite the resident's repeated requests and the family's agreement to find another facility, the first documented referral was not made until January 17, 2024. The facility's Social Service Director (SSD) confirmed that only one referral packet was sent and could not specify any other facilities contacted for the transfer. The resident's medical record lacked documentation of any other referral attempts before January 17, 2024. The resident's progress notes indicated ongoing communication between the facility, the resident, and his family about the transfer. However, the facility's actions were delayed and insufficient. The SSD acknowledged the responsibility for making referrals but failed to provide timely and adequate referrals. The facility's documentation did not support that multiple facilities were contacted, and the only referral made was to a facility 148 miles away from the resident's desired location. This lack of timely action and proper documentation led to the deficiency in providing necessary social services to the resident.
Failure to Document Psychiatric Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic medications unless necessary to treat a specific psychiatric diagnosis documented in the medical record. Specifically, a resident was prescribed Risperidone, an antipsychotic medication, without a documented diagnosis of psychosis or any other psychiatric condition that would justify its use. The resident's medical record, including the care plan and physician's orders, did not contain any documentation of a psychiatric diagnosis to support the administration of Risperidone. The Director of Nursing (DON) confirmed that the resident was sent for a psychiatric evaluation, which led to the prescription of Risperidone, but the evaluation did not document a diagnosis of psychosis or any other psychiatric condition. The deficiency was identified through a review of the resident's admission record, physician's orders, and Medical Administration Record (MAR), as well as an interview with the DON. The DON acknowledged that the psychiatric evaluation did not provide a diagnosis to justify the use of Risperidone and confirmed that the resident's medical record lacked the necessary documentation. This oversight could result in the resident receiving unnecessary medication, increasing the risk of adverse side effects.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident at the time of a planned discharge. The discharge summary for the resident, who was discharged on a specified date, was missing critical information including dietary recommendations, skin condition, current infections, hearing and vision abilities, dental concerns, speech pattern, bowel and bladder continence, assistance levels, signs and symptoms of a change in condition, therapy services received, medication reconciliation, education provided, and other attachments. Additionally, the form was not signed off by staff. During an interview, the Director of Nursing (DON) confirmed that the discharge summary was incomplete and acknowledged that staff are expected to complete the entire discharge summary document prior to the resident being discharged. The DON also confirmed that staff are required to perform a medication reconciliation and provide a copy of the discharge summary and medication reconciliation to the resident, their representative, and/or the home health agency before the resident leaves the facility.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that staff received the appropriate behavioral health training and possessed the skills to provide behavioral health services for a resident with significant behavioral health concerns. The resident exhibited aggressive and disruptive behaviors, including attempting to break into an ashtray, stealing from other residents and staff, making threats of violence, and physically assaulting a nurse. Despite these behaviors, there was no documentation that the provider was notified about the resident's actions, and the resident did not receive any mental health services while in the facility. Interviews with staff revealed that they were not adequately trained to handle such aggressive behaviors. The RN involved in the incidents confirmed that she had not received any training related to behavioral health or dealing with aggressive residents. The Director of Nursing (DON) and the Social Services Director (SSD) also confirmed that while some CNAs had received training on managing aggressive behaviors, the rest of the facility's staff, including nurses and other clinical staff, had not received this training. The SSD provided an 8-hour training on managing aggressive behaviors to some CNAs, but this training was not extended to the entire staff. The lack of comprehensive training and skills competencies for dealing with behavioral health issues and aggressive behaviors contributed to the facility's inability to manage the resident's actions effectively, leading to a deficiency in providing the necessary care and assistance to meet the resident's behavioral health needs.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by a physician for one resident. The resident had a physician's order for a regular/liberalized diet with dysphagia advanced texture, which requires bite-sized, moist foods excluding crunchy, sticky, or very hard foods. However, during an observation, the resident was served whole chicken nuggets and whole French fries, which did not comply with the prescribed diet. This was confirmed by a CNA and the Director of Nursing (DON), who acknowledged that the resident should have been served mechanical soft, chopped bite-sized foods.
Unlocked Treatment Carts
Penalty
Summary
The facility failed to keep treatment carts locked when not supervised by staff, affecting all 61 residents on the 100 and 200 Units. On 05/06/24 at 2:30 PM, an observation of the 100 Unit revealed an unlocked and open treatment cart containing hydrocortisone lotions, scissors, and lancets, with no staff present. This was confirmed by an LPN. On 05/07/24 at 8:58 AM, a similar observation was made on the 200 Unit, with the treatment cart also unlocked and open, containing similar items, and no staff present. The Unit Manager confirmed this observation. The Administrator later confirmed that the expectation is for treatment carts to be locked when not in use.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
