Skies Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 9150 Mcmahon Boulevard Nw, Albuquerque, New Mexico 87114
- CMS Provider Number
- 325064
- Inspections on file
- 30
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Skies Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure that nurse aides in training completed required NATCEP/CEP certification within four months of hire, resulting in two aides working numerous shifts while still uncertified. Review of personnel files and timesheets showed that one aide worked over 150 shifts and another worked over 50 shifts without having completed CNA certification, despite the ADM’s stated expectation that all nurse aides be certified within four months. This deficiency was determined to potentially affect all residents by allowing untrained staff to provide direct care.
Surveyors found multiple failures in medication and supply storage, including loose pills left in and on medication carts, carts left unlocked and unattended in hallways, and expired dressings, syringes, and culture swabs remaining in use areas. A discharged resident’s ceftriaxone vial was still on a treatment cart, and an unwrapped syringe was stored in a drawer. In the medication room, the refrigerator door was found open with an internal temperature far above acceptable range, and expired supplies were present. Staff, including CMAs, an LPN, and an RN, confirmed that these conditions were inconsistent with facility policy and that medications and supplies should have been properly secured, discarded, or removed.
Surveyors found that the facility did not follow its posted lunch menu for all residents when ice cream was served instead of the planned strawberry streusel dessert. Observation of the main dining room showed ice cream being served, while the written menu listed pizza, broccoli, and strawberry streusel. The Dietary Manager reported that a staff call-off required her to cover a shift, she arrived late, and she did not have time to prepare the scheduled dessert, leading to the unplanned substitution.
Surveyors identified multiple failures in food and beverage handling, including undated and improperly sealed ham, diced potatoes, frozen beef patties, grapes, and prepared sandwiches in the kitchen, as well as unlabeled coffee, milk, and juice on a hallway beverage cart. Staff, including the dietary manager, an RN, and a CNA, confirmed that items were not dated, not labeled, and that milk on the cart was not kept on ice as expected. These deficient practices were noted as affecting all residents in the facility census and were described as likely to lead to foodborne illnesses if proper food handling and storage were not followed.
Facility leadership allowed multiple nurse aides in training to work in direct-care roles without documented CNA certification and without appropriate job descriptions. Infection control practices were deficient for a resident on chemotherapy who was placed on modified protection environment and contact plus droplet precautions, as signage did not clearly indicate required PPE and the resident was taken to therapy without consistent use of masks, gowns, or eye protection by staff or nearby residents. Additionally, several residents using O2 and a CPAP device lacked specific physician orders detailing exact liter flow, continuous vs PRN use, or any order at all, while the IDON stated that nurses could adjust oxygen based on their judgment rather than following precise provider orders.
The facility failed to properly implement and follow transmission-based precautions and PPE practices. Infection control policies referenced CDC guidelines requiring clear precaution signage and readily available PPE, but one resident with an indwelling catheter had no transmission-based precaution sign or PPE at the room, and a “Modified Protection Environment” sign on another room did not specify the type of precautions or PPE required. The infection prevention coordinator acknowledged that residents with indwelling catheters should be on Enhanced Barrier Precautions with PPE available and that an additional contact plus droplet sign should have been visibly posted for a specific room. Staff also did not consistently follow posted precautions: a CNA entered a room on special contact and droplet precautions without any PPE despite knowing a gown, N95, and eye protection were required, and an OT left and re-entered a precaution room while wearing the same PPE instead of removing and replacing it between entries.
Surveyors found that staff failed to ensure psychotropic medications were medically necessary and linked to documented diagnoses. One resident with multiple medical and psychiatric conditions was receiving citalopram for depression without having a depression diagnosis. Another resident with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism was receiving fluoxetine and venlafaxine for depression and trazodone for insomnia, despite lacking documented diagnoses of depression or insomnia. The IDON confirmed that these medications were ordered for those indications and that there were no corresponding diagnoses in the clinical records, contrary to the requirement that medications be documented to treat specific diagnosed conditions.
The facility failed to complete accurate MDS assessments for several residents, leading to inconsistencies between documented assessments and actual conditions and treatments. One resident with documented hearing impairment and an audiology referral was recorded as having adequate hearing with no need for hearing aids. Another resident prescribed Pregabalin, an anticonvulsant, was documented as not receiving anticonvulsants. A resident discharged from the hospital with a CPAP and using it nightly was recorded as not using CPAP, and another resident with cerebral palsy and garbled, hard-to-understand speech was documented as having clear speech. These inaccuracies were confirmed by the MDS coordinator and the interim DON.
Surveyors found that the facility did not develop comprehensive care plans for three residents. One resident with an MDRO and on Modified Protective Environment Precautions had no MDRO-related or precaution interventions in the care plan despite an infection alert and signage at the room. Another resident with physician-ordered side rails used them for mobility and repositioning, but the care plan did not address side rail use. A third resident with COPD and other conditions used a CPAP machine nightly, yet the care plan contained no CPAP-related interventions. The DON and IPC acknowledged these omissions.
Surveyors found that the facility failed to maintain clear and accurate respiratory therapy orders and documentation for several residents using supplemental O2 and CPAP. Some residents had O2 orders written as broad ranges (e.g., 1–6 L/min or 1–5 L/min) without a specific flow rate, and one resident receiving O2 had no physician order at all despite the care plan referencing O2 "as ordered." Another resident regularly using a CPAP device had hospital discharge instructions for CPAP but no corresponding physician order, and the CPAP use was omitted from both the care plan and the MDS. In addition, one resident had conflicting O2 orders written both as continuous and PRN, with no clarification of the exact amount to be administered, as confirmed by the DON and IDON.
A resident was found to be using quarter-length bed rails for mobility and repositioning even though the medical record contained no MD order for bed rail use, a bed rail assessment documented that bed rails were not needed, and the baseline care plan lacked any interventions for bed rails or mobility enablers. Observation confirmed bed rails installed on both upper sides of the bed, and the resident acknowledged using them. The IDON later confirmed that one resident’s orders did not specify bed rail size or indication and that this resident had no physician orders or assessment supporting the need for bed rails before they were installed.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying 3 errors in 27 observed opportunities. One resident with a sacral wound did not receive wound care as ordered when an LPN used normal saline instead of the prescribed wound cleanser. Another resident receiving Reglan via PEG-tube was given a dose that had been touched by a surveyor, after a CMA pre-poured medications and then administered the contaminated pill. A third resident prescribed Rybelsus to be taken 30 minutes before food or drink received the medication while finishing breakfast, with the LPN later acknowledging she was unaware of the timing requirement.
Two residents with multiple medical conditions, including DM2, CHF, dementia, and NSTEMI, did not receive dental evaluations after admission despite identified oral health risks and resident reports of dental concerns. One resident with multiple missing teeth and a bothersome broken tooth reported telling staff without resulting in a dental appointment, and her EHR showed only one past dental visit with no follow-up. Another resident with a missing front tooth stated she needed to see a dentist, yet her EHR contained no record of any dental evaluation. The staff member responsible for scheduling acknowledged that both residents had been missed, despite an expectation for annual dental appointments.
Staff failed to protect resident PHI by leaving identifying information and electronic records exposed on unattended medication carts in public hallways. On two separate occasions, a paper listing residents’ full names, room numbers, and code status was left visible on a cart, and a computer displaying residents’ electronic medical records was left unlocked and unattended. An LPN and an RN each confirmed that this information was exposed to public view and not properly secured.
Surveyors found that call lights were not kept within reach for two residents who were asleep in recliners, with the call devices placed on their beds instead. A hospice nurse and a CNA each confirmed in separate interviews that the call lights were not accessible to the residents and acknowledged that they should have been within reach.
A nurse entered a resident’s room without knocking or announcing, failing to respect the resident’s right to dignity and personal space. During observation on a resident hallway, an RN walked directly into the room, and later acknowledged in interview that he should have knocked and announced himself before entering.
A resident admitted with documented diagnoses of major depressive disorder, prolonged grief disorder, PTSD, alcohol dependence, and insomnia had a PASARR Level I Identification Screen completed that indicated no diagnosis of or suspected mental illness. Review of records and an interview with the interim DON confirmed that the PASARR did not accurately reflect the resident’s mental health conditions, resulting in an inaccurate PASARR screening.
A resident admitted with pancytopenia, small B-cell lymphoma, nontraumatic intracerebral hemorrhage, cognitive communication deficit, anemia, and a documented MDRO infection had an infection control alert in the EHR and hospital discharge orders noting MDRO, as well as a posted sign for Modified Protective Environment Precautions. However, the baseline care plan developed within 48 hours of admission did not include any interventions for MDRO or for the use of Modified Protective Environment Precautions, a deficiency later confirmed by the IPC and interim DON.
A resident with DM2 had a physician order for Rybelsus 7 mg to be administered orally once daily, 30 minutes before any food or drink. During a medication pass observation, an LPN gave the Rybelsus dose while the resident was finishing breakfast, not in accordance with the ordered timing. In an interview immediately afterward, the LPN reported not knowing that the medication was required to be given 30 minutes before food or drink.
A resident with a physician order for restorative nursing services three times weekly following discharge from PT did not receive the ordered restorative program. The resident expressed a desire to receive therapy, and the PT confirmed the resident had been discharged from therapy and should be on restorative services. However, restorative documentation showed no evidence that services were provided, and the restorative aide reported she was never notified by PT about the resident’s restorative order, resulting in a lapse in restorative care intended to maintain the resident’s ADL abilities.
A resident with primary progressive MS and other comorbidities, who required assistance with ADLs and transfers, did not receive restorative range of motion (ROM) services as recommended by therapy. The resident was observed in bed with her head tilted toward her shoulder and visible hand contractures and reported believing she was supposed to receive ROM exercises but was not. The Activity Director, responsible for the restorative nursing program, acknowledged that she did not provide ROM or restorative services to this resident, resulting in a cited deficiency for failure to maintain or improve ROM and mobility.
A resident with multiple chronic conditions, including lymphedema and chronic pain, was care planned and assessed as having a Foley catheter, and surveyors observed a urine drainage bag connected to a tube at the bedside. The resident confirmed use of a Foley catheter, but record review showed no physician orders specifying the need for the catheter, its type, or required catheter care. The Interim DON acknowledged that there were no orders in place for the catheter or its care.
Surveyors found that required daily nurse staffing information, including the facility name, current date, RN, LPN, and CNA staffing numbers and hours, and the resident census, was not updated and posted at the main entrance. The posting displayed outdated information from a prior day instead of current data. During an interview, the IDON acknowledged that the staffing data is supposed to be posted every day and confirmed it had not been updated as required.
A resident admitted with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism was prescribed and administered Carbidopa-Levodopa at bedtime with an indication of Parkinson’s disease, despite not having a Parkinson’s diagnosis. Review of the MAR showed the medication was given on multiple consecutive days, and the IDON confirmed that the documented indication did not match the resident’s current diagnoses, resulting in a deficiency related to unnecessary medications.
A resident with colon cancer metastatic to the liver, who was receiving ongoing chemotherapy, missed a scheduled oncology treatment because transportation was not arranged. The resident’s oncology records listed multiple upcoming chemotherapy dates, and the care plan noted active chemotherapy and risk related to cancer treatment. The resident reported that the facility did not provide transport for the appointment, and an oncology clinic RN navigator confirmed there was no transport scheduled. The UC, responsible for arranging transports, stated she was unaware of the appointment and that she relies on nurses to provide appointment information, which did not occur in this case.
A resident with multiple sclerosis and muscle contractures had active MD orders for PT several times per week and a Restorative Nursing Program for ROM, but received only one PT session and no restorative services. The resident reported not having been seen for therapy despite wanting to participate. The Activities Director, who oversees the Restorative Nursing Program, stated she had not received the order to initiate restorative services and confirmed that, although an active RNP order existed, no restorative care was being provided.
The facility did not ensure that a CNA and a NAIT received the required 12 hours of annual in‑service education, including dementia care and abuse prevention. Record review showed that one CNA, hired for direct care, completed only nine and a half hours of in‑service training within the review period, while a NAIT, listed on the staff roster as a CNA and working regularly, had no documented in‑service training at all. In interviews, the DON and the ADM acknowledged that all CNAs and NAITs are expected to complete the required training and confirmed that these two staff members had not met the requirement, with no education files located for the NAIT.
Three residents experienced medication administration errors, including two who received each other's medications and one who was left without a prescribed fentanyl patch for up to 12 hours due to improper handling and delayed replacement. The incidents involved residents with complex medical conditions and were confirmed through interviews and record reviews by nursing leadership.
A resident with quadriplegia and other neurological conditions, who required two-person assistance and a mechanical lift for transfers, was moved from a wheelchair to bed by a single CNA without the lift or nurse supervision. This resulted in a fall and a left shoulder fracture, as confirmed by staff interviews and medical records.
Two residents did not receive medications as ordered: one experienced a delay in starting oral antibiotics after IV antibiotics were discontinued due to the medication not being available in the facility, and another had pain medication administered late in the morning because staff were occupied with other urgent tasks. The DON and LPNs confirmed these delays and deviations from scheduled medication times.
Staffing shortages resulted in missed or delayed showers and prolonged call light response times for all residents. Multiple CNAs and the DON confirmed that low staffing prevented adherence to scheduled bathing routines and timely assistance with ADLs. Residents reported waiting extended periods for care, including remaining in soiled briefs for hours due to insufficient staff.
Two residents with significant physical and cognitive impairments did not receive scheduled assistance with bathing and showering, as documented by missed opportunities and confirmed by staff interviews. Persistent staffing shortages led to incomplete ADL care, resulting in residents going multiple days without baths or showers and appearing unkempt until staff intervened.
A resident with a PEG tube, originally placed for dysphagia after a stroke, continued to have the tube maintained despite no longer requiring tube feeding or medication administration through it. The PEG tube had not been used for several months, and there were no current provider orders for its care, yet it remained in place with only water flushes and site cleaning. The NP admitted to forgetting to reassess the need for the tube, and the DON stated it was kept as a precaution, leading to a deficiency in proper PEG tube management.
A deficiency was identified when a resident with multiple psychiatric and cognitive diagnoses did not have written, signed, and dated physician progress notes after each required visit. The PCP, who was not directly associated with the facility, visited the resident but failed to provide documentation of these visits, as confirmed by the DON. Only one provider note was found in the medical record.
A resident who required assistance with activities of daily living was unable to receive showers as frequently as desired, despite expressing a preference for daily showers. Staff, including the DON and a unit manager, confirmed that short staffing prevented the accommodation of extra showers, as residents could not be left unattended for safety reasons. The resident reported emotional distress due to the inability to shower daily.
A resident who experienced an unwitnessed fall did not have required post-fall neurological evaluations documented in the EHR. Although staff are expected to perform and record neurological checks after such incidents, the necessary documentation was not found in the medical record at the time of review, as confirmed by interviews with nursing and medical records staff.
The facility did not ensure residents received mail on Saturdays due to no staff at the front desk on weekends. Residents expressed their desire to receive mail when it is delivered, but the Activities Assistant confirmed the lack of weekend mail delivery.
The facility experienced staffing shortages, leading to missed baths/showers, delayed meals, and unmet resident needs. Staff interviews confirmed that low staffing levels resulted in missed personal care tasks and delayed medication administration. Residents reported long wait times for call lights and were informed by staff that these delays were due to being short-staffed.
The facility failed to maintain appropriate food holding temperatures during a dinner meal. The turkey was at 134 degrees, steamed broccoli at 128 degrees, and mashed potatoes at 132 degrees, all below the required 135 degrees for hot foods. The Dietary Manager confirmed these temperatures were not within the safe serving range.
The facility failed to deliver meals and snacks consistently and timely, affecting all residents. Lunch meals were often delayed, with trays delivered late to various halls. Residents reported dissatisfaction due to late and cold meals. Additionally, bedtime snacks were not consistently offered, with the Dietary Manager unaware of their distribution by nursing staff.
The facility's kitchen was found unsanitary, with open, unlabeled food items and improper staff hygiene. Sanitizer levels and temperatures were not documented correctly, and a food warmer was visibly soiled. These issues were confirmed by the dietary manager and director of operations.
A resident's privacy was compromised by the assignment of a 1:1 sitter who monitored him at all times in his room due to past inappropriate behaviors. Despite no recent incidents or medical necessity, the sitter's presence was constant, leading to feelings of invasion and lack of privacy for the resident and his mother during visits.
The facility failed to provide adequate ADL assistance for bathing to two residents, who were scheduled for showers but received significantly fewer than planned. Interviews and documentation revealed that the residents were not offered enough showers, and staff confirmed the deficiency.
A facility failed to provide individualized activities for a hospice resident at risk for limited engagement. The resident's care plan required one-to-one room visits with activities based on his interests, but records showed limited participation in activities, specifically watching or listening to TV or movies. An observation revealed the absence of a TV or music device in the resident's room, and staff confirmed this lack, admitting to inaccurate documentation.
The facility failed to ensure proper communication and documentation for two residents requiring dialysis. One resident had incomplete Hemodialysis Communication Records, lacking vital signs and dialysis site checks post-treatment. Another resident had no dialysis communication forms during their stay, despite scheduled sessions and refusals. Interviews confirmed these documentation lapses.
The facility experienced a medication administration error rate of 48% due to late administration of medications to two residents. An LVN unfamiliar with the medication schedule and an LPN delayed by meal tray duties contributed to the late administration of various medications, as confirmed by the DON.
The facility failed to properly store and label medications and medical supplies, including an unlabeled whiskey bottle, expired IV kits, and loose pills. A resident's expired insulin pen was left on their bedside table, confirmed by staff interviews. These deficiencies could impact resident safety.
A resident received an insulin injection in the dining room, compromising their dignity and privacy. The resident preferred injections in the abdomen and in private, but a nurse administered the insulin in the dining area during lunch, leaving the resident feeling they had no alternative but to accept the situation.
A resident's MDS assessment inaccurately reported adequate vision and hearing, despite the resident having significant impairments in both areas. The MDS Coordinator admitted to incorrectly completing the assessment, which could lead to misidentification of clinical complications.
A facility failed to implement a comprehensive care plan for a resident with sexually inappropriate behavior, requiring 1:1 monitoring. Observations showed staff left the resident unsupervised, despite the care plan's requirements. The MDS/Care Planner admitted the care plan hadn't been updated since April 2023 and lacked specific exceptions, leading to inconsistent monitoring.
Failure to Ensure Timely Completion of Nurse Aide Training and Certification
Penalty
Summary
The facility failed to ensure that nurse aides in training completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of employment, resulting in two nurse aides in training working beyond the allowable period without certification. Personnel records showed that one nurse aide in training was hired on 10/09/24 and was scheduled to take the certified nursing aide test on 01/31/26, yet timesheets documented that she worked 151 shifts between 01/01/25 and 12/31/25 without having obtained certification. Another nurse aide in training was hired on 06/29/25 and was also scheduled to take the CNA test on 01/31/26, with timesheets indicating she worked 57 shifts between 08/01/25 and 12/31/25 without certification. In an interview, the Administrator confirmed that both nurse aides in training had not yet received their certification while continuing to work shifts and stated that her expectation was for all nurse aides to become certified within four months of hire. This deficient practice was identified as likely to affect all 109 residents residing at the facility by allowing untrained staff to provide direct care, based on the surveyors’ review of personnel records, timesheets, and the Administrator’s interview statements.
Improper Medication Storage, Expired Supplies, and Unsecured Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s storage and handling of medications and medical supplies. On multiple occasions, loose unidentified pills were observed in and on medication carts, including several tablets and capsules found in a cart drawer and another pill found on top of a sharps container. Staff interviews confirmed that these loose medications should have been disposed of per facility policy and that medication carts are expected to be free of loose pills. Surveyors also observed treatment and medication carts left unlocked and unattended in resident hallways, and staff acknowledged that carts are required to be locked when not in use but were not locked at those times. Additional observations showed expired and inappropriate items stored on treatment carts and in the medication room. A ceftriaxone vial labeled for a resident who had been discharged the previous month remained on the treatment cart, along with an expired Aquacel dressing and an unwrapped syringe in a drawer; staff confirmed the resident’s discharge date and that these items should have been removed or discarded. In the locked medication room, the medication refrigerator door was found open with an internal temperature reading of 52.4 degrees Celsius, and expired culture swab kits and syringes were present. Staff confirmed the refrigerator had been left open and that the culture swab and syringe were expired. These findings were noted as having the potential to affect all 109 residents in the facility.
Failure to Follow Posted Menu and Provide Planned Dessert
Penalty
Summary
The facility failed to follow the planned menu to meet the nutritional needs and preferences of all 109 residents listed on the census when the posted lunch menu was not served as written. During an observation of lunch service in the main dining room at 11:40 a.m. on 01/04/26, residents were served ice cream for dessert. Review of the written lunch menu for that date showed that the planned meal items were pizza, broccoli, and strawberry streusel, indicating that strawberry streusel, not ice cream, was the scheduled dessert. In an interview at 12:16 p.m. on the same day, the Dietary Manager stated that an employee had called off for a shift, requiring her to cover the shift, and that she arrived late to the facility and did not have time to prepare the strawberry streusel, resulting in the substitution of ice cream for the planned dessert. The report states that this deficient practice could prevent residents from eating well, not meeting their nutritional needs, and lead to weight loss.
Improper Food Labeling and Storage Practices in Dietary and Beverage Service
Penalty
Summary
The deficiency involves failure to ensure food was prepared and served under sanitary conditions, including improper labeling and storage of food and beverages. During an observation of the dietary department, surveyors found half of a five-pound boneless ham in the walk-in refrigerator that was not dated, an open five-pound bag of diced potatoes in the walk-in refrigerator that was not sealed properly, and an open ten-pound box of frozen beef patties in the freezer that was not sealed properly. They also observed a five-pound bag of grapes that was open to air, not sealed properly, and not dated, as well as a zip lock bag containing approximately six halves of ham and cheese sandwiches in the refrigerator that were not dated. In an interview, the Dietary Manager confirmed these findings and stated he expected all items to be sealed properly and dated. Additional observations on the 400 hallway beverage cart showed further failures in safe food handling. A kitchen cart was observed with what appeared to be coffee, milk, and juice that were not labeled with contents or date of preparation, and an RN confirmed that the beverages were not labeled or dated and stated that all beverages should be properly labeled. On another observation of the same hallway cart, milk was seen not sitting on ice, and a CNA confirmed that the milk was not on ice and acknowledged that all drinks should be placed on ice to stay cold. These practices were identified as affecting all 109 residents on the census and were described as likely to lead to foodborne illnesses if safe food handling and storage practices were not followed.
Uncertified Staff Use, Inadequate Isolation Practices, and Non-Specific Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s administration, including the Administrator (ADM), Infection Prevention Coordinator (IPC), and Interim Director of Nursing (IDON), failing to ensure staff were properly trained and certified before providing care, failing to implement appropriate infection control practices, and failing to obtain specific medical orders for oxygen and related respiratory devices. Surveyors’ review of personnel files showed that three nurse aides in training (NAITs) had start dates as nurse aides but no evidence of certification as CNAs in their files. The ADM initially reported that these NAITs were certified on specific dates, but the personnel records did not contain proof of certification. The ADM later confirmed that two of the NAITs were still working in a nurse aide capacity without certification and that the third NAIT, who had signed a non-certified nursing aide job description, was being used as transport staff without a transport job description in the file. The deficiency also includes failures in infection control practices for a resident on contact plus droplet precautions and modified protection environment precautions. The facility’s policy referred to CDC guidance, which recommends clear signage outside rooms indicating the type of precautions and required PPE. Observations showed that a resident on chemotherapy had a Modified Protection Environment sign at the doorway listing restrictions such as no plants, flowers, or animal visits and strict hand hygiene, but the sign did not indicate the type of precautions or PPE to be used. The IPC confirmed that an additional sign for contact plus droplet precautions should have been posted but was not initially visible. Later, a contact plus droplet sign was observed with instructions for staff to clean hands and wear gown, gloves, mask, and eye protection. Despite this, the resident was observed in the therapy room without a mask while receiving assistance with hygiene and drinking, with multiple staff and other residents present and no staff wearing gowns or face shields and no other residents wearing PPE. The IPC stated that the resident was only required to wear a mask as tolerated, that the family had requested therapy in the room due to COVID exposure, and that the facility could not force the resident to stay in the room or wear a mask. Further, the facility did not obtain or follow specific medical orders required for oxygen use and CPAP therapy. Record review showed that some residents had oxygen orders written with broad ranges (e.g., one to six liters per minute or one to five liters per minute via nasal cannula) without specifying the exact flow rate or clarifying whether oxygen was to be continuous or PRN. One resident using oxygen and another using a CPAP machine had no corresponding physician orders in the record, despite documentation from a hospital discharge indicating that CPAP use was ordered for a resident with acute and chronic respiratory failure with hypoxia. During interview, the IDON confirmed that the oxygen orders lacked specific flow rates and that residents using oxygen and CPAP should have orders but did not. The IDON also stated that orders did not need to specify the amount of oxygen because nurses would use their judgment to keep oxygen saturation above 90, reflecting a failure to recognize that specific orders are required for oxygen use.
Failure to Implement and Follow Transmission-Based Precautions and PPE Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow an ongoing infection prevention and control program, specifically related to transmission-based precautions and staff adherence to posted precautions. Facility infection control policies dated 05/01/25 directed staff to follow CDC guidelines, which require clear signage outside rooms indicating the type of precautions and PPE to be used, PPE availability outside resident rooms, access to alcohol-based hand rub in every room, and trash cans positioned inside rooms near exits for PPE disposal. Observations on the 100 hall showed multiple rooms with various precaution signs and PPE caddies, including a “Modified Protection Environment” sign that did not specify the type of precautions or PPE required, and rooms on special contact, droplet, and enhanced barrier precautions. One resident with an indwelling catheter did not have any transmission-based precaution signage or PPE available, despite the infection prevention coordinator later confirming that residents with indwelling catheters should be on Enhanced Barrier Precautions with PPE available. The infection control coordinator was also observed removing a contact plus droplet precaution sign from a PPE caddy, and the infection prevention coordinator acknowledged that an additional contact plus droplet sign should have been visibly posted for a specific room. The deficiency also includes staff not following the precautions that were posted. A CNA entered a room on special contact and droplet precautions without wearing any PPE and confirmed in interview that he knew the room required a gown, N95 respirator, and eye protection or face shield when entering, but he did not use them. An OT was observed exiting a room while still wearing full PPE, walking down the hall, and then re-entering the room with the same PPE, and later confirmed he should not have exited the room before removing PPE and should don new PPE each time he enters. These observations and interviews demonstrate that staff did not consistently adhere to required transmission-based precautions and PPE use as outlined by CDC guidelines and facility policy.
Psychotropic Medications Administered Without Corresponding Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure psychotropic medications were prescribed and documented as medically necessary to treat specific, diagnosed conditions. For one resident with end stage renal disease, dependence on dialysis, paranoid schizophrenia, bipolar disorder, presbyopia, and post-traumatic stress disorder, record review showed an order for citalopram 10 mg at bedtime for depression. The Interim Director of Nursing (IDON) confirmed that the indicated use of citalopram is depression and that this resident did not have a diagnosis of depression. The IDON also confirmed that medications should be documented to treat specific conditions as diagnosed, and this was not done for this resident. For another resident with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism, record review showed orders for fluoxetine 20 mg daily and venlafaxine 75 mg daily, both indicated for depression, and trazodone 150 mg (2 tablets at bedtime) indicated for insomnia. During interview, the IDON confirmed that the indicated uses for fluoxetine and venlafaxine were depression and for trazodone was insomnia, and that this resident did not have diagnoses of depression or insomnia. The IDON further confirmed that medications should be documented to treat specific conditions as diagnosed and that this requirement was not met for these psychotropic medications.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments for multiple residents, resulting in discrepancies between documented assessments and residents’ actual conditions and treatments. One resident with documented impaired hearing, a care plan noting impaired communication due to hearing loss, and a physician’s order for an audiology consult was recorded on the MDS as having adequate hearing and requiring no hearing aids. Another resident with a physician’s order for Pregabalin, an anticonvulsant prescribed twice daily for chronic pain syndrome, was documented on the MDS as not taking anticonvulsant medications, despite the ongoing order. Additional inaccuracies were identified for two other residents. One resident admitted with multiple diagnoses, including COPD with acute exacerbation, vascular dementia, dysphagia, Crohn’s disease, and insomnia, had been discharged from the hospital with a CPAP machine and reported using it nightly since admission, yet the MDS indicated no CPAP use. Another resident with cerebral palsy and a care plan noting impaired communication, garbled speech, and difficulty making herself understood was documented on the MDS as having clear speech. In each case, the MDS coordinator or Interim DON confirmed that the MDS entries were incorrect based on the residents’ actual conditions and treatments.
Failure to Include MDRO Precautions, Bed Rails, and CPAP Use in Resident Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement accurate, comprehensive care plans for multiple residents as required. One resident with diagnoses including pancytopenia, small B-cell lymphoma, nontraumatic intracerebral hemorrhage, cognitive communication deficit, and anemia was admitted with a hospital discharge diagnosis of a multidrug-resistant organism (MDRO) and an infection prevention alert for wound and E. coli MDRO. Despite this, the resident’s care plan dated the day after admission did not include any interventions related to MDRO or the facility’s Modified Protective Environment Precautions, even though a sign for these precautions was posted by the resident’s door. The Infection Prevention Coordinator confirmed the MDRO diagnosis and the use of Modified Protective Environment Precautions, and the Interim DON confirmed that these interventions were not reflected in the care plan and should have been. Another resident, admitted with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism, had a physician order for assist/side rails x2 starting shortly after admission. Observation showed quarter-size bed rails on both upper sides of the bed, and the resident reported using the side rails for mobility and repositioning. However, review of the resident’s care plan revealed no intervention addressing the use of side rails. The Interim DON confirmed that the care plan should have included the use of side rails but did not. A third resident, admitted with COPD with acute exacerbation, vascular dementia, oropharyngeal dysphagia, Crohn’s disease, and insomnia, was observed with a CPAP machine next to the bed and stated that the CPAP was used every night since admission. Review of this resident’s care plan showed no interventions related to CPAP use. The Interim DON confirmed that the facility failed to develop and implement a care plan that included the resident’s use of a CPAP machine and stated that residents are expected to have care plans that include all required interventions, including CPAP use.
Failure to Maintain Accurate Respiratory Therapy Orders and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards for multiple residents using supplemental oxygen and a CPAP device. For one resident with spastic quadriplegic cerebral palsy, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and epilepsy, the medical order dated 03/21/23 directed oxygen at “one to six liters per minute” via nasal cannula continuously, without specifying an exact flow rate. This resident was observed in bed on oxygen via nasal cannula connected to a concentrator, and the Interim DON confirmed the order did not specify the exact amount of oxygen needed. Another resident with COPD, iron deficiency anemia, chest pain, muscle weakness, and peripheral vascular disease was observed wearing a nasal cannula attached to an oxygen concentrator, with a current order dated 03/29/25 for “three to four liters of oxygen per minute” via nasal cannula, again without a precise flow rate; the DON confirmed the order did not specify the exact amount of oxygen this resident should receive. A third resident with pneumonia, COPD, pulmonary hypertension due to lung disease and hypoxia, chronic kidney disease stage 2, and iron deficiency anemia was observed wearing a nasal cannula connected to an oxygen concentrator, but record review of the physician record showed no orders for oxygen use or oxygen device care. The care plan dated 03/25/25 noted the resident was at risk for respiratory complications related to COPD and stated “O2 as ordered,” yet there was no corresponding physician order. The DON confirmed that this resident did not have an order for oxygen use and should have had one. Another resident with COPD with exacerbation, vascular dementia, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and pneumonia had a CPAP machine at bedside and reported using it every night, with hospital discharge documentation ordering CPAP use. However, the MDS dated 12/02/25 indicated the resident did not use a non-invasive ventilator, the care plan dated 03/29/25 did not include CPAP use, and there was no current physician order for CPAP; the DON confirmed the resident uses CPAP and that the order, MDS, and care plan were not accurate to the resident’s needs. A fifth resident with dementia, mild intermittent asthma, permanent atrial fibrillation, obstructive sleep apnea, and a cardiac pacemaker was observed wearing a nasal cannula connected to a portable oxygen concentrator attached to the wheelchair. This resident’s medical orders dated 12/31/25 included one order to wear oxygen at “one to five liters” via nasal cannula continuously and another order to have oxygen at “one to five liters” via nasal cannula as needed. The Interim DON confirmed that these orders did not specify the exact amount of oxygen required and did not clarify whether the resident needed continuous or PRN oxygen. Across these residents, surveyors identified missing or incomplete physician orders, lack of specific oxygen flow rates, and inaccurate or incomplete documentation in the care plan and MDS related to respiratory therapies.
Failure to Obtain Orders and Complete Assessments Prior to Bed Rail Installation
Penalty
Summary
The deficiency involves the facility’s failure to obtain appropriate physician orders and complete required assessments before installing bed rails for a resident. The resident was admitted on a specified date, and record review showed no physician order for bed rail use, a bed rail assessment indicating the resident did not need bed rails, and a baseline care plan without any interventions for bed rails or mobility enablers. Despite this documentation, surveyors observed quarter-length bed rails installed on both upper sides of the resident’s bed, and the resident reported using the side rails for mobility and repositioning. In an interview, the Interim DON confirmed that one resident’s physician orders lacked the size and indication for bed rail use and that this resident had no physician orders or assessment documenting the need for bed rails prior to their installation. These findings show that the facility did not follow its own process of assessing safety risk, reviewing risks and benefits with the resident/representative, obtaining informed consent, and correctly ordering and documenting bed rail use before installation.
Failure to Maintain Medication Error Rate Below 5%
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 27 observed opportunities, resulting in an 11.11% error rate. For one resident with a physician’s order dated 10/15/25 for sacral wound care specifying cleansing with wound cleanser, patting dry, applying zinc, and then applying an optifoam dressing, an LPN instead used normal saline in place of the ordered wound cleanser during a wound care procedure on 01/08/26. In a subsequent interview, the LPN stated he could not find wound cleanser and decided to use normal saline, confirming he did not follow the physician’s order. For another resident with a physician’s order dated 08/05/25 for Reglan 5 mg via PEG-tube four times daily for gastric motility, a CMA had pre-poured medications into cups labeled with room numbers. During observation of medication administration on 01/04/26, a surveyor accidentally touched a green oblong pill stamped “Reglan 5” in one of the cups, and the CMA, who witnessed this contact, proceeded to crush and administer the contaminated pill via PEG-tube. For a third resident with a physician’s order dated 11/04/25 for Rybelsus 7 mg by mouth once daily, to be taken 30 minutes before food or drink, an LPN administered the medication while the resident was finishing breakfast on 01/06/26. In an interview immediately afterward, the LPN stated she did not know the medication should be given 30 minutes before any food or drink.
Failure to Ensure Dental Evaluations for Two Residents
Penalty
Summary
The facility failed to ensure that residents received necessary dental services, resulting in two residents not being evaluated by a dentist after admission. One resident was admitted with multiple diagnoses including a history of TIA, CHF, diabetes mellitus, dementia, and depression. Her care plan, initiated several months after admission, identified that she exhibited or was at risk for oral health or dental care problems due to multiple missing teeth. During an interview and observation, this resident reported she had not been to a dentist since admission, had several missing teeth, and stated that a broken tooth was bothering her, which she had reported to several staff members without resulting in a dental appointment. Her EHR showed only a single dental appointment dated several months after admission, with no further documentation of dental evaluations. Another resident, admitted with type 2 diabetes mellitus, acute CHF, and NSTEMI, stated during interview that she needed to go to the dentist and was observed to have a missing front tooth. Review of her EHR revealed no documentation that she had been evaluated by a dentist since admission. In an interview, the facility Scheduler confirmed that both residents had not been seen by a dentist since admission, despite her stated expectation that all residents have an annual dental appointment. She acknowledged that she attempts to keep up with scheduling annual dental visits for all residents and had missed scheduling for these two residents.
Failure to Protect Resident PHI on Medication Carts
Penalty
Summary
The facility failed to safeguard residents’ protected health information (PHI) and maintain confidentiality of medical records in accordance with accepted professional standards. On 01/05/26 at 2:11 pm, surveyors observed a white piece of paper on a medication cart outside a resident room that listed multiple residents’ full names, room numbers, and code status, left unattended and visible in a hallway accessible to the public. During an interview at 2:15 pm, an LPN acknowledged that the paper contained resident identifiers and confirmed it should have been kept out of public view but was not. On 01/07/26 at 8:46 am, surveyors again observed a breach when the computer on a medication cart outside another resident room was left unlocked and unattended, displaying residents’ electronic medical records and exposed to public view. At 9:02 am, an RN confirmed that the electronic health record had been left exposed and unattended.
Failure to Keep Call Lights Within Reach for Residents in Their Rooms
Penalty
Summary
Surveyors identified a deficiency in ensuring that resident call lights were within reach while residents were in their rooms. During observation on 01/05/25 at 10:34 am, one resident was found asleep in a recliner while the call light was lying on top of the bed, out of the resident’s reach. In a concurrent interview at 10:36 am, a hospice nurse confirmed that the call light was not within the resident’s reach and stated that it should have been. In a separate observation on 01/05/25 at 8:58 am, another resident was also found asleep in a recliner with the call light placed on the bed, again out of reach. During an interview at 9:05 am, a CNA confirmed that this call light was not within the resident’s reach and acknowledged that it should have been accessible. These findings show that for two of four residents reviewed for call light accessibility, staff did not ensure that the call lights were positioned so the residents could use them while in their recliners, despite staff acknowledging that the call lights should have been within reach.
Failure to Knock and Announce Before Entering Resident Room
Penalty
Summary
The facility failed to honor a resident’s right to dignity and respect by not knocking or announcing before entering the resident’s room. During a random observation of the 400-hall on 01/04/26 at 8:40 a.m., a Registered Nurse (RN #5) walked directly into Resident #22’s room without knocking or announcing himself. In a subsequent interview at 8:42 a.m., RN #5 confirmed that he should have knocked and announced himself prior to entering the room. This deficiency was identified for 1 of 9 residents reviewed for dignity and respect and was noted as likely to impact residents’ dignity and respect for their personal space. No additional medical history or clinical condition for Resident #22 was provided in the report.
Inaccurate PASARR Level I Screening for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected a resident’s mental health diagnoses. Record review showed that the resident was admitted with documented diagnoses of major depressive disorder, prolonged grief disorder, PTSD, alcohol dependence, and insomnia. However, the resident’s PASARR Level I Identification Screening, completed on 10/23/25, indicated that the resident did not have a diagnosis of or a suspected mental illness. During an interview, the Interim Director of Nursing confirmed that the PASARR did not accurately reflect the resident’s diagnoses. This inaccuracy between the resident’s admission record and the PASARR Level I screen constituted the deficiency identified by surveyors for one of two residents reviewed for PASARR accuracy.
Failure to Include MDRO and Protective Precautions in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple significant diagnoses, including pancytopenia, small B-cell lymphoma, nontraumatic intracerebral hemorrhage, cognitive communication deficit, anemia, and a documented multidrug-resistant organism (MDRO) infection. Hospital discharge orders listed MDRO, and the resident’s electronic health record contained an infection prevention and control alert for a wound with E. coli MDRO, with an onset date matching the hospital discharge. Despite this information, the baseline care plan created the day after admission did not include any interventions related to MDRO. The baseline care plan also omitted interventions for the use of Modified Protective Environment Precautions, even though the resident was placed on these precautions as an alternative to neutropenic precautions. A subsequent observation showed a sign posted next to the resident’s door indicating Modified Protective Environment Precautions were in place. In interviews, the infection prevention coordinator confirmed the MDRO diagnosis and the use of Modified Protective Environment Precautions, and the interim DON confirmed that the resident’s care plan lacked interventions for MDRO and the need for Modified Protective Environment Precautions, despite these being necessary based on the resident’s condition and orders.
Failure to Follow Physician Order for Timing of Diabetes Medication
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when staff did not follow a physician’s medication order for a resident with type 2 diabetes. Record review showed a physician’s order dated 11/04/25 for Rybelsus 7 mg to be given by mouth once daily, 30 minutes before any food or drink. During a medication administration observation on 01/06/26 at 8:41 a.m., an LPN administered the Rybelsus dose while the resident was finishing breakfast, contrary to the ordered timing. In a subsequent interview at 8:43 a.m., the LPN stated she did not know the medication should be given 30 minutes before any food or drink. This deficient practice was cited for one resident reviewed and was identified as a failure to follow physician orders, which the report states is likely to result in residents not maintaining their optimal health as planned by their medical provider.
Failure to Provide Ordered Restorative Nursing Services After Therapy Discharge
Penalty
Summary
The facility failed to ensure that a resident received ordered restorative services to prevent loss of ability in activities of daily living. During an interview, the resident stated she wanted some type of therapy, even if only restorative therapy. The PT confirmed that the resident had been discharged from therapy, could not recall the discharge date, and acknowledged that the resident should be receiving restorative therapy. Record review showed a physician order dated 12/23/25 referring the resident to the restorative nursing program three times a week for improved quality of life, but the restorative therapy notes contained no indication that the resident was actually receiving restorative services. In a subsequent interview, the restorative aide stated that when PT discharges a resident, PT is supposed to notify her, and she confirmed she had not been notified about this resident’s restorative program order. According to the report, if the facility is not ensuring residents receive restorative services at the commencement of therapy services when indicated, residents are likely to experience a decrease in their activities of daily living.
Failure to Provide Ordered Restorative ROM Services
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative physical therapy services and devices as recommended by the therapy department for a resident with multiple complex medical conditions. The resident was admitted with non-active primary progressive multiple sclerosis, delusional disorder, unspecified tremors, uninhibited neurogenic bladder, and a nonrheumatic mitral valve disorder. The resident’s care plan, dated 12/13/25, documented that she required assistance with basic ADLs, including transfers, due to MS, and that her call light should be kept within reach. Despite these identified needs and the expectation for restorative services, the resident did not receive the restorative range of motion program that she believed she was supposed to have. During an observation on 01/05/26 at 6:10 p.m., the resident was seen lying in bed with her head positioned near her left shoulder and visible contractures of both hands. She stated she thought she was supposed to receive range of motion exercises from the restorative program, reported that she was not receiving them, and expressed that she would like to receive them. In a subsequent interview on 01/06/26 at 9:15 a.m., the Activity Director, who stated she was responsible for the restorative nursing program, confirmed that she did not offer range of motion or restorative nursing services to this resident. The surveyors determined that this failure to provide restorative services was likely to result in pain and decreased mobility, causing psychosocial harm and despair.
Lack of Physician Orders for Foley Catheter Use and Care
Penalty
Summary
The deficiency involves the facility’s failure to obtain and maintain physician orders specifying the necessity, type, and care of a Foley catheter for a resident with an indwelling catheter. The resident was admitted with diagnoses including lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism. Review of the physician orders showed no orders for the use of a Foley catheter or for catheter care, despite documentation elsewhere indicating catheter use. The resident’s MDS dated 12/25/25 documented the presence of a catheter in Section H, and the care plan dated 12/19/25 stated the resident required a Foley catheter due to skin impairment. During a random observation of the resident’s room, surveyors observed a tube connected to a bag containing what appeared to be urine hanging from the bed, consistent with a Foley catheter. In a subsequent interview, the resident confirmed that she uses a Foley catheter. The Interim DON later confirmed that the resident did not have physician orders for the use of a Foley catheter or for catheter care, despite the documented and observed presence of the catheter.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required daily nurse staffing information at the beginning of each shift, including the facility name, current date, total number and actual hours worked by RNs, LPNs, and CNAs directly responsible for resident care per shift, and the resident census. On observation at 11:30 AM, the nurse staffing data posted at the main entrance was dated two days prior and had not been updated for the current day, despite a current census of 109 residents as reported by the Administrator. In an interview shortly thereafter, the Interim Director of Nursing confirmed that the nurse staffing data is required to be posted daily and acknowledged that it had not been posted for the current day. This deficient practice was identified by surveyors through direct observation of the posting location and through staff interview, establishing that the facility was not in compliance with daily staffing posting requirements on the day of the survey.
Medication Administered Without Appropriate Diagnosis-Based Indication
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not verifying an appropriate indication for a prescribed medication consistent with the resident’s current diagnoses. Record review showed the resident was admitted with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism. The physician record contained an order for Carbidopa-Levodopa 25-100 mg, one tablet by mouth at bedtime, with the stated indication of Parkinson’s disease, starting 12/18/25. The Medication Administration Record for January 2026 showed the resident received this medication daily from 1/01/26 through 1/05/26. During an interview, the Interim DON confirmed the resident did not have a diagnosis of Parkinson’s disease and that the indication documented for the medication did not reflect the resident’s current diagnoses. This resulted in a deficiency related to unnecessary medications for one of two residents reviewed for unnecessary drugs, as the medication was administered without an appropriate, diagnosis-based indication of use.
Failure to Arrange Transportation for Chemotherapy Appointment
Penalty
Summary
The facility failed to provide transportation for a scheduled oncology chemotherapy appointment for one resident, resulting in a missed treatment. The resident’s face sheet showed admission with malignant neoplasm of the colon, secondary malignant neoplasm of the liver and intrahepatic bile duct, and an encounter for antineoplastic chemotherapy. An oncology visit record dated 12/09/25 documented upcoming chemotherapy treatment dates, including an appointment on 12/30/25. The resident’s care plan dated 05/08/25 identified him as being at risk for adverse reactions related to colorectal cancer with metastasis to the liver and noted that he was currently receiving chemotherapy. During an interview, the resident reported that he missed his 12/30/25 chemotherapy treatment because the facility did not provide transportation, and stated that the facility receives copies of all his appointments and that he had been attending weekly chemotherapy since admission. An oncology clinic RN navigator confirmed that the resident missed the 12/30/25 appointment and stated that there was no transport scheduled when she called the facility. The Unit Clerk, who is responsible for scheduling transport for residents’ appointments, reported she was not aware of the 12/30/25 oncology appointment and confirmed the resident missed the appointment due to the inability to provide transport. She further explained that she schedules transport based on information received from the nurses, and in this instance, that process did not occur.
Failure to Provide Ordered Physical Therapy and Restorative Nursing Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered rehabilitative services within a reasonable timeframe for one resident. The resident reported not having been in therapy and that no one had seen her about therapy, despite her desire to participate. Record review showed she had multiple diagnoses, including non-active primary progressive multiple sclerosis, contractures of muscles in the right lower leg, left leg, and right upper arm, and secondary progressive multiple sclerosis unspecified. A prior PT evaluation documented an order for PT five times per week for four weeks, and a later PT treatment note showed that only one PT session had occurred. Further record review revealed an active physician’s order for PT three times per week for 30 days for skilled PT services, including ROM, safe transfers, and bed mobility, as well as an order for a Restorative Nursing Program three times per week for passive ROM to the bilateral lower extremities and active ROM to the bilateral upper extremities. The Activities Director, who oversaw the Restorative Nursing Program, stated she had not received an order from the Director of Therapy to initiate the program for this resident and confirmed that, despite the active RNP order, the resident was not receiving any restorative services. This lack of implementation of both PT and restorative nursing orders led to the identified deficiency.
Failure to Provide Required Annual In‑Service Training for CNA and NAIT
Penalty
Summary
The facility failed to ensure that CNAs and NAITs received the required 12 hours of annual in‑service training, resulting in two staff members not meeting this requirement. Personnel records showed that one CNA, hired on 04/17/24, had completed only nine and a half hours of in‑service training between 01/27/25 and 09/23/25. Another staff member listed on the facility’s staff list as a CNA was actually a NAIT hired on 10/09/24, whose in‑service transcript showed zero hours of training from hire through 12/31/25, despite working a total of 151 days during that period. In interviews, the DON and the Administrator each stated they expect all CNAs and NAITs to complete the required annual training and confirmed that these two staff members had not done so, with the Administrator also confirming that no education files could be found for the NAIT. These findings demonstrate that the facility did not provide or document the mandated annual in‑service education for the identified CNA and NAIT, specifically including dementia care and abuse prevention training referenced in the deficiency statement, as required for staff responsible for resident care.
Failure to Administer Medications as Prescribed and Improper Medication Management
Penalty
Summary
The facility failed to administer medications as prescribed for three residents, resulting in medication errors and improper medication management. For one resident with diagnoses including congestive heart failure, diabetes with neuropathy, and atrial fibrillation, the medication administration record showed that the resident received medications that were not prescribed to him. The resident identified the error after noticing differences in the appearance of the pills and reported the issue to the Business Office Manager, who found that the medications in the resident's possession actually belonged to his roommate. The Director of Nursing later confirmed that the medications administered and documented did not match the medications dispensed for each resident. Another resident, with chronic kidney disease, hemiparesis, hypertension, visual disturbances, and major depressive disorder, was also involved in the medication error. This resident could not recall which pills were administered but remembered being advised by his roommate not to take the pills as they were not his. The resident did recall receiving his eye drops. The Director of Nursing was informed that medications found in the first resident's possession did not belong to him, leading to the determination that the wrong medications were given to both residents. A third resident, diagnosed with metastatic breast and bone cancer, diabetes, hypertension, polyarthritis, and anxiety disorder, experienced an issue with the administration of a fentanyl patch. A nurse reported that the patch was nearly detached and not properly secured, and a replacement patch was not available until the following day, resulting in the resident being without the patch for approximately 12 hours. Additionally, it was confirmed that a CNA attempted to remove or cut the fentanyl patch, and conflicting documentation existed regarding the duration of the lapse in coverage.
Failure to Use Required Mechanical Lift and Two-Person Assist During Transfer
Penalty
Summary
A resident with diagnoses including demyelinating disease of the central nervous system, quadriplegia, and anoxic brain damage was admitted to the facility and had a care plan requiring transfer by mechanical lift with two-person assistance and nurse supervision. Despite these documented requirements, a certified nursing aide (CNA) transferred the resident from a wheelchair to bed alone, without the use of a mechanical lift and without nurse supervision. This incident resulted in the resident experiencing a fall and subsequently sustaining a left shoulder fracture, as confirmed by an X-ray and follow-up by a nurse practitioner. Interviews with the resident and staff confirmed that the transfer was performed by a single CNA without adherence to the prescribed safety protocols. The resident reported hearing a pop and feeling pain during the transfer, later learning of the collar bone fracture. Staff interviews corroborated that the CNA did not use the mechanical lift or have a second person present, as required by the resident's care plan. The incident was documented in the facility's records, and the CNA involved was suspended pending investigation.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents. One resident did not receive prescribed oral antibiotics on time following a hospital discharge, as the medication was not available in the facility. The hospital discharge orders specified that oral antibiotics were to begin after intravenous antibiotics were discontinued, but there was a delay of two days before the oral antibiotics were started. The Director of Nursing confirmed that the medication was ordered but not received from the pharmacy until several days after it was needed. Another resident did not receive pain medication at the scheduled time. The resident reported that pain medications were often administered late, specifically noting a delay in receiving the morning dose. Review of the medication administration record showed that the scheduled administration times were not consistently followed, and staff interviews confirmed that the pain medication was given late due to a busy morning and competing priorities. The Director of Nursing acknowledged that the pain medication was administered late and should have been given on time.
Insufficient Staffing Leads to Missed Showers and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 114 residents, resulting in missed or delayed showers and baths, as well as prolonged response times to call lights. Multiple certified nursing assistants (CNAs) reported being the only staff member on their unit during several shifts, which prevented them from adhering to the scheduled bathing routines and completing other assigned duties. The Director of Nursing and the Unit Manager both confirmed ongoing staffing shortages and acknowledged that these issues directly impacted residents' activities of daily living (ADLs), including personal hygiene care. Residents reported significant delays in having their call lights answered, with one resident stating she waited an average of three hours while in a soiled brief, and another noting long wait times at night due to only one CNA being present for the entire floor. Staff interviews corroborated these accounts, with CNAs confirming that low staffing levels led to delays of up to an hour or more in responding to residents' needs. These findings demonstrate that the facility did not have adequate staff on duty to ensure timely and appropriate care for all residents.
Failure to Provide Scheduled Bathing and Showering Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and showering, for two residents who were unable to perform these tasks independently. One resident, with limited mobility, a history of multiple fractures, chronic obstructive pulmonary disease, pain, and obesity, was scheduled for baths or showers three times a week. Documentation showed that this resident received only six out of thirteen scheduled baths or showers in one month, and three out of seven in the following two weeks. The resident reported going seven days without a bath or shower, expressing embarrassment and distress over the situation. Staff interviews revealed that persistent short staffing was a significant factor contributing to missed showers and baths. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) confirmed that the facility was often unable to complete all scheduled showers, especially for bedbound residents. One CNA, originally hired as a designated shower aide, was reassigned to other duties due to staffing shortages, making it difficult to complete the required number of showers. The Director of Nursing acknowledged that ongoing staff vacancies were impacting the ability to maintain the shower schedule. A second resident, with dementia, schizophrenia, and chronic obstructive pulmonary disease, was also scheduled for regular baths or showers. Documentation indicated that this resident received only seven out of twenty-five scheduled baths or showers over a two-month period, and at times, went without any offered or provided showers for multiple scheduled opportunities. Observations noted the resident appeared disheveled and unkempt, with clothing and hygiene issues addressed only after staff intervention. The lack of consistent ADL care was directly linked to staffing shortages, as confirmed by multiple staff interviews.
Failure to Reassess and Remove Unused PEG Tube
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and a percutaneous endoscopic gastrostomy (PEG) tube was not managed according to current standards of practice. The resident had a PEG tube placed during a hospital stay due to dysphagia and was admitted to the facility with the tube in place. Provider orders indicated the resident was to receive a dysphagia diet and enteral water flushes, but there were no current orders for PEG tube care, feeding, or medication administration through the tube. Documentation showed the resident was consuming regular meals and no longer required tube feeding since January, yet the PEG tube remained in place and was only being maintained with water flushes and site cleaning. During interviews, the resident confirmed that the PEG tube had not been used for nutrition for several months and that staff had informed her it might be removed soon. The nurse practitioner acknowledged forgetting to reassess the need for the PEG tube, despite it no longer being used for its original purpose. The director of nursing stated the tube was being kept as a precaution due to the resident's risk of another stroke. The failure to reassess and remove the unused PEG tube, and the lack of updated provider orders for its care, constituted the deficiency.
Lack of Physician Progress Notes After Resident Visits
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's physician reviewed care and provided written, signed, and dated progress notes after each required visit. The resident, who was admitted with diagnoses including delusional disorders, major depressive disorder, and dementia, had a primary care provider (PCP) not directly associated with the facility but with admitting privileges. Review of the resident's electronic medical record revealed an absence of physician notes documenting visits, with only a single provider note dated several months prior available. The Director of Nursing confirmed that while the PCP did visit the resident occasionally, no documentation of these visits was left or provided for the resident's medical record.
Resident Shower Preferences Not Honored Due to Staffing Shortages
Penalty
Summary
The facility failed to honor and facilitate a resident's preference for daily showers, as required by regulations supporting resident choice and self-determination. Record review showed that the resident was scheduled for showers three times per week, but the resident expressed a desire to shower every day. During interviews, the resident reported being unable to shower as often as preferred due to a shortage of Certified Nursing Assistants (CNAs), and stated that nursing staff informed her that additional showers could not be accommodated because of staffing limitations. The resident described experiencing negative emotions such as anger, sadness, and dread when unable to receive daily showers. Staff interviews confirmed that residents are not permitted to shower alone due to safety concerns, and that short staffing directly impacts the ability to provide showers beyond the scheduled times. The Unit Manager and Director of Nursing both acknowledged that while residents are allowed more frequent showers in theory, in practice, staffing shortages prevent this from occurring. The Director of Nursing specifically confirmed that extra showers are not allowed when the facility is short staffed, resulting in the resident's preferences not being honored.
Missing Documentation of Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to ensure that medical records were updated with post-fall neurological evaluations for a resident who experienced an unwitnessed fall. Record review showed that the resident was found between beds with a curtain over her head and her leg over a bedside table leg. Although nursing staff are required to begin neurological checks immediately after being notified of an unwitnessed fall and to document these evaluations using a specific form, the resident's electronic health record did not contain the required post-fall neurological assessments. Interviews with staff confirmed that the neurological evaluations were not present in the medical records at the time of review, and the Director of Nursing later acknowledged that the documentation should have been included in the resident's electronic health record but was not.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents have access to their mail on Saturdays, affecting all 114 residents. During a resident council meeting, several residents expressed that they do not receive mail on Saturdays, which they would like to have when it is delivered to the facility. An interview with the Activities Assistant revealed that the absence of staff at the front desk on weekends is the reason for the lack of mail delivery on Saturdays.
Staffing Shortages Lead to Missed Care and Delays
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of all 114 residents, resulting in missed baths or showers, delayed meals and snacks, and unmet resident needs. Interviews with staff, including CNAs, LPNs, and RNs, confirmed that low staffing levels led to residents missing scheduled baths and showers. Additionally, it was noted that these personal care tasks were not completed at night due to the same staffing issues. The deficiency also affected the timely administration of medications and meal services. An LPN reported that medications were administered late because she was required to assist with meal tray distribution. The Activities Director mentioned that due to frequent staff call-ins, she sometimes had to help answer call lights. Residents expressed dissatisfaction during a council meeting, stating that they experienced long wait times for call lights to be answered and were informed by staff that the delays were due to being short-staffed.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food holding temperatures during a dinner meal observation. On September 4, 2024, at 5:37 pm, the turkey was found to be at 134 degrees, steamed broccoli at 128 degrees, and mashed potatoes at 132 degrees. These temperatures are below the required 135 degrees for hot foods. During an interview at 5:39 pm, the Dietary Manager confirmed that the temperatures of the turkey, steamed broccoli, and mashed potatoes were not within the safe serving range, which should be 135 degrees or above for hot foods and 41 degrees or below for cold foods.
Inconsistent Meal and Snack Delivery
Penalty
Summary
The facility failed to deliver meals consistently and timely, affecting all 114 residents. Observations revealed that lunch meals were scheduled to be served at 12:00 pm, but were consistently delayed. On multiple occasions, meal service in the dining area began late, and trays were delivered to various halls significantly after the scheduled time. Interviews with the Dietary Manager confirmed the consistent lateness of meal service. Residents expressed dissatisfaction, reporting that meals arrived late and were often cold. During a Resident Council meeting, multiple residents complained about the consistent delay in meal service. Additionally, the facility failed to deliver snacks consistently and timely. Resident Council members reported not being offered bedtime snacks. Interviews with several residents confirmed the lack of snack distribution. The Dietary Manager stated that snacks were available in the nourishment room and were scheduled to be provided at specific times, but the responsibility for distributing snacks lay with the nursing staff. The Dietary Manager was unaware if snacks were being delivered or accessible to residents once they were prepared by the kitchen.
Sanitation and Documentation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during a survey. Several food items in the walk-in refrigerator were found open to air, unlabeled, and undated, including flour tortillas, salsa, green chile, puree food, juice, Swiss cheese, shredded cheese, and shredded carrots. Additionally, a can of Mountain Dew and a personal cell phone were found on the food prep area. These practices could lead to cross-contamination and the growth of foodborne pathogens. Furthermore, staff members were not adhering to proper hygiene protocols; a dietary aide was observed without a hairnet, and another staff member's beard guard did not cover all facial hair. The facility also failed to document the correct sanitizing solution levels and temperatures for the dish machine, with missing entries for several days. The required sanitizer concentration was not consistently recorded, and the temperature logs were incomplete. Additionally, the kitchen's cleanliness was compromised, as evidenced by a food warmer with visible spills, spatters, and rust, which contained food items to be served to residents. These deficiencies were confirmed through interviews with the dietary manager and director of operations for dietary services.
Resident Privacy Compromised by 1:1 Sitter Assignment
Penalty
Summary
The facility failed to ensure the privacy of a resident, identified as R #56, by assigning a 1:1 sitter to monitor him at all times, both day and night, in his room. This practice was implemented due to a past history of sexually inappropriate behavior towards female staff and residents, as noted in the resident's care plan. However, there was no current physician order for the 1:1 care, and recent records did not document any sexually inappropriate behaviors, although there were instances of the resident hitting staff and refusing medications. Observations revealed that the sitter consistently sat at a table inside the doorway of the resident's room, partially blocking the entrance. Interviews with the sitter, Director of Nursing (DON), and Nurse Practitioner (NP) confirmed the sitter's role was to prevent the resident from leaving his room and entering female residents' rooms. The NP noted that the 1:1 sitter was not a medical necessity and had not been requested by her, and there had been no recent incidents of inappropriate behavior. The resident and his mother expressed feelings of invasion of privacy due to the constant presence of the sitter. The resident reported feeling like he was in jail, unable to have private conversations with his mother or participate in activities, leading to feelings of sadness and loneliness. The mother also noted a lack of privacy during her visits, as staff were usually present in the room.
Inadequate ADL Assistance for Bathing
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the area of bathing and showering. Resident #96, who required assistance due to memory changes, anxiety, depression, and pain, was scheduled for showers on Mondays, Wednesdays, and Fridays. However, records indicate that the resident received only four out of ten scheduled showers from August 7 to August 31, and none from September 1 to September 5. Interviews with the resident and staff confirmed that the resident was not offered enough showers, and the lack of documentation further supported this deficiency. Similarly, Resident #105, who needed assistance due to decreased mobility and pain, was scheduled for showers on the same days. The records show that the resident received only two out of eight scheduled showers from August 6 to August 23. Interviews with the resident's son-in-law and staff corroborated that the resident was not provided with sufficient bathing opportunities. The Director of Nursing confirmed the inadequacy of the bathing schedule for both residents, acknowledging that they should have been offered more showers.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests of a resident, identified as R #72, who is a hospice patient at risk for limited and/or meaningful engagement. The resident's care plan specified the need for one-to-one room visits with activities individualized to his interests. However, a review of the Activity Individual Resident Daily Participation Record for August 2024 showed that the resident only participated in watching or listening to TV or movies 15 times, with no documentation of invitations or refusals to participate in other activities. An observation on September 6, 2024, revealed that the resident's room lacked a television or music listening device, and interviews with staff confirmed the absence of these items. The Activity Assistant admitted to inaccurate documentation regarding the resident's participation in activities.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis facility for two residents requiring dialysis services. For one resident, there were incomplete Hemodialysis Communication Records on multiple dates, indicating a lack of documentation regarding vital signs and dialysis site checks post-treatment. Interviews with a registered nurse and the Director of Nursing confirmed that the forms were not completed as required, and the expected protocol of checking vital signs and the dialysis site was not followed. For the second resident, the facility did not maintain any dialysis communication forms during the resident's stay, despite the resident having scheduled dialysis sessions. The resident refused dialysis twice, but there was no documentation to reflect these refusals or any other dialysis-related information. Interviews with a licensed practical nurse and the Director of Nursing confirmed the absence of completed dialysis communication forms, which should have been filled out for each dialysis session.
Medication Administration Errors Due to Late Administration
Penalty
Summary
The facility was found to have administered medications with an error rate greater than 5%, specifically a 48% error rate, due to late administration of medications. Two residents were affected by this deficiency. For Resident #33, medications including Acetaminophen, Aspirin, GlycoLax Powder, Senna, Vitamin B Complex, Cyclobenzaprine, Hydrochlorothiazide, and Metformin were administered past their scheduled times. The Licensed Vocational Nurse (LVN) responsible for administering these medications was not familiar with the medication times and routines as she was normally assigned to another hall. The Director of Nursing confirmed that the medications were administered late, outside the acceptable window of one hour before or after the scheduled time. For Resident #54, medications such as Duloxetine, Meloxicam, Oxacarbazepine, and Oxybutynin were also administered late. The Licensed Practical Nurse (LPN) involved stated that she was delayed in administering the medications because she was required to assist with passing morning meal trays. This resulted in the medications being given after the scheduled administration time, contributing to the overall medication error rate.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and medical supplies, as observed during a survey. On the 400 unit, a gallon of whiskey was found unlabeled in the medication room refrigerator, and an expired IV dressing change kit was discovered. Additionally, four boxes of laxative enemas were found with expired dates. On the 200 Unit Medication Cart, a loose round white pill was found in the second drawer. Interviews with staff confirmed these findings, with a registered nurse acknowledging the whiskey should have been labeled and a certified medication assistant confirming that loose pills or expired medications should be discarded. In another instance, a Basaglar Insulin injectable pen with an expired date was found on a resident's bedside table. The resident, who had a physician's order for insulin administration for Diabetes Mellitus Type II, stated that a nurse left the insulin pen there. This was confirmed by a certified nurse aide and the nurse involved, who admitted the pen should not have been left in the resident's room. These deficiencies in medication storage and labeling practices could potentially compromise resident safety if not addressed.
Insulin Injection Administered in Dining Room
Penalty
Summary
The facility failed to uphold the resident's rights to dignity and privacy by administering an insulin injection in a public setting. During a lunch hour observation, a resident was seated in the dining area when an unidentified nurse approached and injected the resident with insulin in the left upper arm. The resident later confirmed that he preferred his insulin injections to be administered in his abdomen and in the privacy of his room. He expressed dissatisfaction with the nurse's decision to administer the injection in the dining hall, feeling he had no choice but to comply with the nurse's actions.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Comprehensive Minimum Data Set (MDS) Assessment for a resident, which could lead to misidentification of clinical complications. During an observation and interview, the resident was found to have significant hearing and vision impairments, specifically being unable to hear unless spoken to loudly and close to the ear, and having no vision in the right eye. However, the resident's quarterly MDS assessment inaccurately indicated that the resident had adequate vision and hearing. The MDS Coordinator acknowledged completing the MDS incorrectly, admitting that the resident's hearing and vision should have been coded as not adequate.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who exhibited sexually inappropriate behavior. The care plan, dated April 2023, required 1:1 monitoring to protect all individuals. However, observations on multiple occasions revealed that staff members left the resident's room without ensuring that another staff member was designated to provide the required 1:1 monitoring. This lack of supervision occurred even though the care plan was understood by staff, according to the Minimum Data Set (MDS)/Care Planner. The MDS/Care Planner acknowledged that the care plan had not been updated since April 2023 and did not include specific exceptions for when the resident's mother was present or when the resident was asleep. Despite the staff's understanding of these exceptions, the care plan did not explicitly state them, leading to inconsistent implementation of the required monitoring. This oversight in the care plan documentation contributed to the deficiency in providing adequate supervision for the resident.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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