Socorro Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Socorro, New Mexico.
- Location
- 1203 Highway 60 West, Socorro, New Mexico 87801
- CMS Provider Number
- 325073
- Inspections on file
- 21
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Socorro Wellness & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that medications were not properly managed, with expired drugs present in both the medication storage cabinets and the electronic medication dispensing machine. Two bottles of Daily Multivitamin tablets and one bottle of ibuprofen 200 mg tablets in the cabinets were past their expiration dates, as were one tablet of amlodipine 5 mg and two tablets of sertraline 25 mg in the dispensing machine. The ADON confirmed these findings and acknowledged that staff were expected to remove expired medications but had not done so.
The facility failed to submit complete and accurate Payroll Based Journal (PBJ) direct care staffing data for all residents, resulting in missing documentation of 24-hour licensed nursing coverage on multiple dates in a specific quarter. Review of the PBJ Staffing Data Report showed no recorded licensed nurse coverage for several identified days, and the Regional Director reported that the current company, which assumed ownership later, was unable to obtain nursing staff clock-in and clock-out records from the prior owner for those dates, leading to incomplete staffing information submitted to the federal agency.
A resident with dementia, major depressive disorder, anxiety, and restlessness was prescribed quetiapine 50 mg twice daily for agitation and anxiety and received the medication over multiple months. Review of the medical record showed no order for, or documentation of, AIMS assessments despite the ongoing antipsychotic use. During interview, the Regional Clinical Nurse confirmed that the resident lacked an appropriate diagnosis for antipsychotic therapy and that staff did not complete the required AIMS assessments, contrary to facility expectations for psychotropic medication use and monitoring.
The facility failed to provide required written information related to hospital transfers and bed-hold policies for multiple residents. Two residents were transferred to the hospital, one for weakness and another for hypotension, without any documented written transfer notices in their medical records, despite the Regional Clinical Nurse confirming that such notices should be completed and given to the resident or representative. Another resident was sent from dialysis to the hospital, diagnosed with pyogenic arthritis of the right hip, and later transferred to another nursing home at the family’s request; there was no bed-hold notice in the record, and the Social Service Worker reported not recalling notifying the ombudsman and stated that nursing handled bed-hold and transfer documentation.
Surveyors found that the facility did not develop complete, person-centered care plans reflecting physician orders and clinical needs for several residents. One resident with a Foley catheter had orders for routine and PRN catheter care, changes, and irrigation, but none of these interventions were included in the care plan. Another resident receiving Suboxone for chronic pain had no care plan addressing this opioid therapy. A resident with COPD and chronic respiratory failure, who required high-flow nasal cannula connected to two oxygen concentrators, PRN Albuterol-Budesonide, head-of-bed elevation, and weekly oxygen equipment changes, had none of these respiratory interventions documented in the care plan. A further resident treated with Apixaban for a history of pulmonary embolism did not have this anticoagulant therapy or its associated risks reflected in the care plan, as confirmed by clinical leadership.
Surveyors found that staff failed to keep multiple residents’ care plans current with new medical orders, resolved conditions, and observed behaviors. One resident using supplemental O2 did not have oxygen use or tubing change interventions reflected in the care plan. Two residents receiving antipsychotic, antidepressant, and diuretic medications had no care plan documentation of these drugs or monitoring for side effects. Another resident with a history of falls had an ordered anti‑rollback wheelchair device and a previously painful tooth infection; the care plan did not show that the device was in place, list related interventions, or update the status of the resolved dental infection. A resident with dysphagia on a pureed diet was observed eating snack cakes and reported routinely choosing foods inconsistent with the ordered diet, but the care plan did not address this noncompliance.
A resident repeatedly reported severe leg pain and burning with urination over an extended period, yet staff failed to identify and document open, discolored wounds with scabbing on both lower legs in routine skin assessments and did not record or follow up on the resident’s complaints of dysuria. Some CNAs and an LPN were aware of the leg wounds but did not ensure they were documented or that the provider and DON were notified, while the ADON and another LPN performing skin assessments documented no skin impairments. The resident’s ongoing reports of pain and burning with urination were not reflected in the medical record, and the LPN who heard the complaint did not document it and was unsure whether the provider was notified.
Three residents with chronic respiratory conditions did not receive oxygen therapy according to physician and hospice orders, and staff failed to document required respiratory assessments. One resident ordered for continuous oxygen at 1–2 LPM was repeatedly observed without a nasal cannula and with the concentrator off, while nursing leadership acknowledged he was only using oxygen at night and as needed. Another resident on hospice had conflicting oxygen orders between hospice (8–10 LPM) and the facility (6–8 LPM); staff allowed the resident to adjust his own oxygen, documented use of oxygen flows outside the ordered range during episodes of shortness of breath, and did not record full respiratory assessments or consistent provider notification. A third resident ordered for continuous oxygen starting at 2 LPM had an incorrectly entered order and was observed in bed without the nasal cannula and with the concentrator off, stating staff had forgotten to put the oxygen on, while an LPN confirmed the resident should have been on continuous oxygen.
The facility failed to ensure multiple residents received necessary and routine dental services. One resident with ongoing dental problems did not have a missed follow-up appointment rescheduled after previously refusing it. Another resident reported a broken bottom front tooth and having told staff, yet no dental appointment was made, and both an LPN and the SSC were unaware of the issue or of the requirement for annual routine dental visits. A resident who had dentures on admission was later observed without any teeth or dentures, with the SSC unaware the dentures were missing and no dental appointment arranged. Another resident had no documented routine dental care for an extended period, and the SSC confirmed no routine dental appointment had been scheduled.
The facility failed to maintain complete and accurate records for three residents receiving oxygen therapy. One resident with chronic respiratory failure and bronchitis had repeated oxygen saturation entries that noted nasal cannula use but never included the oxygen concentrator flow rate, despite an order specifying 1–2 LPM. Another resident on hospice with COPD and chronic respiratory failure had hospice admission orders for 8–10 LPM via nasal cannula, while a subsequent physician order in the chart listed 6–8 LPM, and staff repeatedly documented oxygen saturations without recording the concentrator rate. A third resident with chronic respiratory failure had admission orders for continuous oxygen starting at 2 LPM, but the physician order in the record directed increasing oxygen by 2 LPM, and staff again documented oxygen saturations with nasal cannula use but omitted the concentrator rate. The ADON confirmed the mismatched orders and missing oxygen flow documentation, as well as the expectation that staff correctly enter orders and record oxygen concentrator settings.
A family member reported that money and a check provided to facility staff to be placed in a resident’s account were missing, and a grievance documented that $140 given for this purpose had disappeared. The Business Office Manager later told the family member there was no record of an account or funds for the resident. Although this allegation of misappropriation of funds was documented internally, the facility did not submit the required incident report to the State Agency within 24 hours, as confirmed by the Regional Director.
A resident’s family member reported giving $140 in cash to facility staff and having a check from a prior facility sent for deposit into the resident’s account, but later was told by the BOM that there was no record of any account or funds for the resident. A grievance documented that the money had disappeared, and the RD confirmed there was no evidence that a thorough investigation into the alleged misappropriation of the resident’s funds was conducted, despite the expectation that the administrator investigate all such allegations.
A resident’s MDS admission assessment was found to be inaccurate when staff failed to document that the resident was edentulous. The resident’s family reported the resident had only upper dentures prior to admission, and subsequent observation and interviews with the resident and a CNA confirmed the resident had no natural teeth or dentures in the facility. The MDS Coordinator acknowledged that the resident had been without teeth or dentures since admission and that the admission MDS did not correctly reflect the resident’s edentulous status.
Two residents were affected when staff failed to follow physician orders and professional standards of practice. For a resident with serious cardiac conditions on daily amiodarone with parameters to hold the dose for low BP or pulse, staff documented administering the medication but did not consistently obtain or document BP readings, with only a few BP entries recorded over multiple months despite daily dosing. For another resident with a left hand contracture ordered to wear a modified palm guard splint daily or as tolerated, the resident was observed without the splint, CNAs were unaware of the ongoing need or location of the device, the care plan did not reflect any non-compliance, and the splint order was discontinued by hospice without consultation with the OT who had ordered it.
A resident with multiple urinary conditions, including infection related to an indwelling ureteral stent and kidney/ureter calculi, had physician orders for Foley catheter care every shift and catheter changes every 30 days, with additional orders to change and irrigate the catheter as needed. Documentation showed one refused catheter change and one completed change, but no evidence of required monthly changes in subsequent months. An LPN and the ADON reported that the 30‑day catheter change order was incorrectly entered and automatically discontinued, resulting in the catheter being changed only once over several months, contrary to the physician’s orders and facility expectations.
Surveyors found that two residents on hospice services did not have any hospice visit documentation or a coordinated hospice–facility care plan in their medical records or in the hospice binder. One resident with dementia and another with COPD had physician orders for hospice admission, but staff reported that the hospice provider did not supply visit notes or care plans, leaving an LPN unsure of hospice visit schedules and service responsibilities. The ADON, medical records clerk, and regional clinical nurse all confirmed that hospice documentation and coordinated care plans were expected but not provided or available for these residents.
A resident was observed using a loose, aftermarket bed rail that moved side to side along the length of the bed when the resident attempted to use it to get up. Record review showed no documentation that the bed rail had been inspected for proper installation. During interview, the ADON confirmed the rail was not sturdy and reported not knowing whether it had ever been inspected, demonstrating a failure to ensure the bed rail and bed were compatible and safely installed.
A staff member at the facility exhibited neglectful and abusive behavior, including leaving the building frequently, wearing air pods, and falling asleep during a shift. The staff member also used foul language and threatened other staff, creating an unsafe environment for residents. The incident was reported to the police, who found alcohol in the staff member's car.
The facility failed to report abuse and neglect allegations involving a traveling CNA who was found asleep, smelled of alcohol, and threatened staff. The incident, witnessed by residents, was reported to the State Agency a week late, delaying corrective actions.
A facility failed to ensure a CNA from an outside agency completed required abuse, neglect, and exploitation (ANE) training before working with residents. The CNA began working without the necessary training, and the facility did not verify training completion with the agency. This oversight highlights a deficiency in the facility's onboarding process for agency staff.
The facility failed to store and label food and spices according to professional standards, affecting all 43 residents. Observations revealed an improperly sealed and unlabeled bag of chicken nuggets, as well as expired and undated spices. The Lead confirmed these deficiencies, acknowledging that staff should have sealed, dated, and discarded expired items.
The facility failed to maintain an effective infection prevention and control program due to the absence of a water management program to minimize Legionella risk. Staff, including the DON and Maintenance Worker, were unaware of responsibilities and lacked necessary resources like a water system map. The Water Management Plan did not list responsible team members, potentially affecting all 43 residents.
A facility failed to provide a prescribed turmeric supplement to a resident due to unavailability, as documented in the MAR. The CMA indicated the family did not supply the supplement, and there was no record of communication with the pharmacy or family. The DON confirmed the lack of documentation and acknowledged the facility's responsibility to ensure the resident received the supplement.
The facility failed to develop comprehensive care plans for two residents, leading to potential unawareness of their needs. One resident's plan lacked interventions for oxygen and pain management, while another's plan did not document the reason for antipsychotic medication use or measurable objectives. The DON confirmed these deficiencies.
A resident's care plan was not updated after she lost her lower dentures. Despite the resident mentioning the loss and staff confirming it, the care plan did not reflect this change. The oversight was acknowledged by the DON, indicating a lapse in updating the resident's care plan.
A resident's blood pressure medication was not administered according to physician orders, which specified holding the medication only if the systolic blood pressure was less than 100. On several occasions, the medication was withheld without documentation of a systolic blood pressure below the threshold, and no additional blood pressure readings were recorded at the time. The DON confirmed the staff's failure to follow the orders and document appropriately.
A resident with dementia and a history of falls experienced a decline in functional abilities after a wrist fracture. Despite healing, the LTC facility did not implement a restorative nursing program or refer the resident for therapy, resulting in continued substantial/maximal assistance needed for ADLs. Staff interviews confirmed the lack of follow-up actions to restore the resident's prior level of functioning.
Two residents did not receive restorative rehabilitation services as ordered, leading to a deficiency in maintaining or improving their range of motion and mobility. Despite being discharged with therapy instructions, there was no documentation of ROM exercises being performed by CNAs, and the facility lacked a restorative program. The DON confirmed the absence of such a program, and the MDSC acknowledged the lack of documentation.
A resident was prescribed Seroquel for dementia with irritability/agitation/aggression without an appropriate diagnosis, as dementia is not a suitable condition for this medication. The resident had multiple diagnoses, including Alzheimer's and major depressive disorder, but the use of Seroquel was not justified. The DON confirmed the expectation for appropriate diagnosis was not met.
The facility failed to properly store medications for 17 residents in the East Unit. A loose white round tablet was found in the medication cart's second drawer, not contained in a bubble pack or pill container. This was confirmed by a CMA, indicating a deficiency in medication storage that could lead to improper administration and adverse effects.
Expired Medications Found in Storage Cabinets and Electronic Dispensing Machine
Penalty
Summary
Surveyors identified a deficiency related to the storage and management of medications and biologicals. During an observation of the medication room, they found two bottles of Daily Multivitamin tablets and one bottle of ibuprofen 200 mg tablets stored in the medication storage cabinets past their labeled expiration dates. Additional expired medications were found in the electronic medication dispensing machine, including one tablet of amlodipine 5 mg and two tablets of sertraline 25 mg, all with expiration dates that had already passed at the time of the survey. In an interview conducted shortly after the observation, the ADON confirmed the presence of the expired medications in both the medication storage cabinets and the electronic dispensing machine. The ADON also confirmed that staff were expected to remove expired medications from these storage areas. The presence of expired medications in both the cabinets and the dispensing machine demonstrated that this expectation was not followed, affecting the facility’s compliance with requirements for proper labeling and storage of drugs and biologicals.
Failure to Submit Complete and Accurate PBJ Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the federal agency overseeing certification for long term care facilities for Quarter #4 (July 1, 2024–September 30, 2024), affecting all 59 residents identified on the Resident Matrix. Review of the Payroll Based Journal (PBJ) Staffing Data Report for that quarter showed no licensed nursing coverage documented for 24 hours per day on thirteen specific dates: 07/14/24, 08/04/24, 08/11/24, 08/18/24, 08/25/24, 09/01/24, 09/08/24, 09/13/24, 09/14/24, 09/15/24, 09/21/24, 09/22/24, and 09/28/24. During an interview on 12/12/2025 at 12:47 PM, the Regional Director stated that the current company assumed ownership on 11/01/25 and was unable to obtain clock-in and clock-out records for nursing staff from the previous ownership for those same dates in Quarter #4, resulting in incomplete PBJ staffing data submission.
Failure to Ensure Appropriate Diagnosis and AIMS Monitoring for Antipsychotic Use
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that a resident receiving a psychotropic medication had an appropriate psychiatric diagnosis and required monitoring. One resident was admitted with diagnoses including dementia, senile degeneration of the brain, major depressive disorder, a personal history of other mental and behavioral disorders, anxiety, and restlessness and agitation. Physician orders showed that this resident was prescribed quetiapine fumarate 50 mg twice daily for agitation, initially for a short period and then again for agitation and anxiety, and medication administration records documented that the resident received this antipsychotic medication over multiple months. Record review of the resident’s entire medical record revealed no order for an Abnormal Involuntary Movement Scale (AIMS) assessment and no documented AIMS assessments, despite the ongoing use of quetiapine. During interview, the Regional Clinical Nurse confirmed that the resident had an order for quetiapine for agitation and anxiety, did not have an appropriate diagnosis for the use of an antipsychotic medication, and that staff were expected to ensure residents were not administered antipsychotic medications unless they had a specific psychiatric diagnosis. The Regional Clinical Nurse also confirmed that staff did not complete an AIMS assessment on this resident and that staff were expected to complete an AIMS assessment prior to starting an antipsychotic medication and at least every three months thereafter.
Failure to Provide Written Hospital Transfer Notices and Bed-Hold Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer notices and bed-hold information to residents and/or their representatives in connection with hospitalizations. One resident was admitted to the facility and later sent to the hospital due to weakness; review of the entire medical record showed no documented written notice of transfer for this hospitalization. The Regional Clinical Nurse confirmed that staff did not complete a transfer notice for this hospital transfer and stated that staff were expected to complete a written transfer notice when a resident was transferred to the hospital and to give a written copy to the resident or their representative. Another resident, admitted earlier in the year, was sent to the hospital for hypotension, and record review similarly revealed no documented transfer notice for that hospitalization; the Regional Clinical Nurse confirmed that no transfer notice was present and that a notice should have been provided. A third resident, admitted in mid-year, was sent from dialysis to the hospital, where a CT scan revealed pyogenic (septic) arthritis of the right hip, and was later transferred to another nursing home at the family’s request. The Social Service Worker stated that the facility learned of the hospital transfer from the dialysis center, did not recall notifying the ombudsman when the resident transferred to another nursing home, and indicated that nursing staff were responsible for admission documentation for bed holds and transfers. The Regional Clinical Nurse confirmed there was no bed-hold notice in this resident’s record and that staff were expected to complete the state bed-hold notice.
Failure to Develop Comprehensive, Person-Centered Care Plans for Catheter, Respiratory, Pain, and Anticoagulant Management
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, person-centered comprehensive care plans with measurable goals and timeframes for multiple residents. For one resident with an indwelling Foley catheter and diagnoses including infection due to ureteral stent, kidney and ureteral calculi, and obstructive and reflux uropathy, physician orders directed catheter changes every 30 days, catheter care every shift, catheter changes as needed for leakage or drainage, and catheter irrigation as needed. However, the resident’s care plan did not include any interventions addressing Foley catheter care, scheduled catheter changes, PRN catheter changes, or catheter irrigation. The MDS coordinator and the Regional Clinical Nurse (RCN) confirmed that these catheter-related interventions were not included in the care plan and that they should have been documented there. Another resident with a diagnosis of chronic pain syndrome had a physician’s order for Suboxone sublingual film to be given three times daily for chronic pain. The resident’s care plan, dated the same day as the order, did not document that the resident was receiving Suboxone or include a specific plan related to this opioid medication. During interview, the RCN confirmed that the care plan did not include a plan for Suboxone and stated that her expectation was that a specific plan would be in place for this type of medication. A third resident with COPD, chronic respiratory failure with hypoxia, a solitary pulmonary nodule, and dependence on supplemental O2 had orders for PRN Albuterol-Budesonide inhalation aerosol, O2 via nasal cannula at 6–8 L/min, elevation of the head of bed or use of a pillow for shortness of breath, and weekly changes of O2 tubing and concentrator filter. An LPN reported that this resident used a special high-flow nasal cannula connected to two O2 concentrators. The care plan did not document the need for the special high-flow nasal cannula, the use of two concentrators, weekly replacement of nasal cannula and concentrator filter, head-of-bed elevation or pillow use, or the PRN Albuterol-Budesonide order. The ADON confirmed these omissions and stated that all respiratory interventions should be on the care plan. A fourth resident, readmitted with a diagnosis of pulmonary embolism and an order for Apixaban twice daily as a blood thinner, also lacked care plan documentation that the resident was taking Apixaban for a history of pulmonary embolism or that addressed the risks associated with this medication; the RCN confirmed the absence of a care plan for Apixaban and stated that a specific plan including risks was expected.
Failure to Revise Care Plans for New Orders, Resolved Conditions, and Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise and maintain accurate, up‑to‑date care plans for multiple residents after changes in medical orders, conditions, or behaviors. For one resident with chronic respiratory failure and chronic bronchitis, physician orders were in place for oxygen via nasal cannula and for weekly changes of oxygen tubing and water on the concentrator, yet the care plan dated after these orders did not include any interventions related to oxygen use or weekly nasal cannula changes. During interview, the Regional Clinical Nurse (RCN) confirmed that the care plan lacked these oxygen-related orders and that staff were expected to document oxygen and nasal cannula orders in the care plan. Another resident with dementia, major depressive disorder, anxiety, and a history of other mental and behavioral disorders had physician orders for quetiapine fumarate for agitation and anxiety and Lasix for edema. The care plan did not document that the resident was receiving an antipsychotic or a diuretic, nor did it include any monitoring interventions for these medications. The RCN confirmed that the care plan had not been revised to reflect the use of quetiapine fumarate or Lasix and that staff were expected to revise care plans when residents start antipsychotic or diuretic medications. A separate resident with lack of coordination, gait abnormalities, and muscle weakness had an order for an anti‑rollback device on the wheelchair and a prior care plan entry for a painful tooth infection with a planned dental visit. The care plan documented only that the resident would be evaluated for an anti‑rollback lock, without documenting that the device had been installed or listing interventions for its use, and it continued to list an active tooth infection even after the infection had resolved and the resident had seen a dentist. The MDS Coordinator confirmed the infection was no longer current and stated the care plan should have been updated when it resolved, and the DON stated care plans should reflect current interventions and be updated when a diagnosis is resolved. For another resident with dysphagia on a prescribed pureed, thin‑liquid diet, observation and interview showed the resident disliked the pureed diet, preferred to choose foods such as cottage cheese, crackers, and snack cakes, and had chocolate snack cakes at the bedside. The dietitian confirmed that chocolate snack cakes did not match the ordered diet consistency and that the resident tended to pick and choose foods, favoring meat and desserts. The care plan, however, did not document that the resident was noncompliant with the ordered diet. The RCN confirmed that the care plan lacked a revision to address this noncompliance and that her expectation was for a specific plan addressing the resident’s noncompliance. A further resident with psychotic disorder with delusions, major depressive disorder, and anxiety disorder had physician orders for quetiapine fumarate three times daily for psychosis and sertraline once daily for depression. The care plan, last revised before these orders, did not document the antipsychotic or antidepressant medications or any monitoring interventions for them. The RCN confirmed that the care plan had not been revised to include these medications or monitoring for side effects and reiterated that staff were expected to revise care plans when residents start antipsychotic or antidepressant medications. Across these cases, record review, observation, and staff interviews showed that care plans were not revised to reflect current physician orders, resolved conditions, new medications, or resident noncompliance, resulting in care plans that did not contain the most current resident information and interventions.
Failure to Identify and Document Resident Wounds and Pain Complaints
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a resident who reported significant pain and had undocumented wounds. Over a period of months, the resident stated he experienced severe burning pain with urination and significant leg pain, and reported these concerns to multiple staff members. On observation, the resident’s lower legs were discolored with open wounds and scabbing on both legs. However, multiple weekly skin assessments documented no skin impairments and did not identify any wounds on the lower legs. The ADON, who completed a skin assessment on one of those dates, confirmed she did not document any wounds and did not recall seeing any at that time, and another LPN who usually performed the resident’s skin assessments reported awareness only of a wound on the resident’s hand, not the legs. Interviews revealed that some staff were aware of the leg wounds but did not ensure they were assessed or documented, nor was there documentation that the provider or DON were notified. The DON confirmed she had not been made aware of the leg wounds until the surveyor observation. Additionally, although the resident repeatedly complained of burning with urination, there was no documentation in the medical record of these complaints, no record that the provider was notified, and no evidence of follow-up. One LPN acknowledged that the resident told her it was “burning down there,” but she was confused about the location of the pain, was unsure if she notified the provider, and did not document the complaint. The resident continued to report leg pain and burning with urination during interviews with the surveyor and ADON.
Failure to Follow Oxygen Therapy Orders and Document Respiratory Assessments
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for oxygen therapy for three residents with chronic respiratory conditions. One resident with chronic respiratory failure with hypoxia and simple chronic bronchitis had a physician’s order for continuous oxygen via nasal cannula at 1–2 LPM. Surveyors observed this resident sitting in a wheelchair without a nasal cannula, with the oxygen concentrator turned off, and the resident stated he only wore oxygen at night and as needed during the day. On another observation in the dining area, the resident again was not wearing a nasal cannula and did not have a portable oxygen concentrator. An LPN and the ADON both stated that the resident used oxygen at night and as needed during the day, despite the physician’s order for continuous oxygen, and the ADON stated staff were expected to ensure residents wore oxygen as ordered and notify the provider if a change in condition indicated the order might need to be changed. A second resident, admitted with COPD, chronic respiratory failure with hypoxia, a solitary pulmonary nodule, and dependence on supplemental oxygen, had conflicting oxygen orders between hospice and the facility. Hospice admission orders directed oxygen via nasal cannula at 8–10 LPM, while the physician’s order in the facility record specified 6–8 LPM for COPD. Progress notes documented that staff found the resident’s oxygen concentrator at 10 LPM and educated him that it should be at 8–10 LPM, but there was no documentation that a provider was notified or that a full respiratory assessment was completed. Subsequent notes showed the concentrator was decreased to 15 LPM (outside the 6–8 LPM order, with no documentation of the prior setting), and that hospice was notified, but again there was no documented respiratory assessment beyond oxygen saturation. Another entry described an episode of shortness of breath with oxygen saturation dropping to 42%, treatment with ordered albuterol and anxiety medications, and oxygen increased to 14 LPM, outside the ordered range, without documentation of a respiratory assessment or provider notification. An LPN later stated she was not aware of the hospice order for 8–10 LPM, that the resident usually had oxygen at 10 LPM, and that although she assessed lung sounds, she never documented a respiratory assessment. The ADON confirmed staff were expected to assess respiratory status at least every shift, ensure facility orders matched hospice admitting orders, and notify the provider if higher oxygen concentrations were needed. A third resident with chronic respiratory failure had admission orders for continuous oxygen starting at 2 LPM and increasing to keep oxygen saturation greater than 90%. The physician’s order in the record, however, was entered as an order to increase oxygen requirement by 2 LPM to keep oxygen saturation greater than 90%, which did not match the admission order to start at 2 LPM. During one observation, the resident was in bed wearing a nasal cannula with the concentrator set at 3 LPM. On a later observation, the resident was in bed with the nasal cannula lying on the oxygen concentrator, the concentrator turned off, and the resident stated staff had put her to bed after lunch and forgot to put her oxygen on. An LPN confirmed the resident should always wear her nasal cannula, that the concentrator was usually set at 3 LPM, that the order was to start at 2 LPM and increase to keep saturation above 90%, and that at the time of observation the resident was not wearing the nasal cannula and should have been. A regional clinical nurse later confirmed the oxygen order had been entered incorrectly and reiterated that residents should wear oxygen as ordered unless they refuse, with physician notification and documentation required if they refuse. The report states that if the facility is not assessing respiratory status and following orders for oxygen use, the resident may be low on oxygen, which could potentially cause health concerns such as shortness of breath, confusion, rapid heart rate, fatigue, and cyanosis.
Failure to Provide and Coordinate Necessary and Routine Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents obtained necessary and routine dental services. One resident reported ongoing problems with his teeth and stated he was supposed to see a dentist, but staff had not made an appointment; records showed he had a prior dental visit with a follow-up scheduled that he refused, and the Social Services Coordinator (SSC) acknowledged that the follow-up appointment was never rescheduled. Another resident reported that his bottom right front tooth had broken a couple of months earlier, that he had informed staff who said they would send him to the dentist, and he could not recall his last dental visit; observation confirmed a broken bottom right front tooth. An LPN stated she was unaware of the broken tooth and that staff were supposed to notify the SSC of dental needs, while the SSC confirmed she did not know about the broken tooth, had not scheduled an appointment for it, did not know when this resident last saw a dentist, and was unaware that residents were to be scheduled at least annually for routine dental appointments. A third resident’s family member reported that the resident had top dentures on admission, had lost bottom dentures prior to admission, and had not seen a dentist since admission. The resident later stated she had no teeth or dentures, reported having dentures but not knowing what happened to them, and was observed without natural teeth or dentures; the SSC stated she was not aware the resident was missing dentures and had not made a dental appointment for dentures. For another resident, the power of attorney stated the resident had not been to the dentist for an unknown but lengthy period, possibly years, and record review showed no documentation of routine dental care; the SSC confirmed she had not scheduled a routine dental appointment for this resident. The Regional Clinical Nurse stated that staff were expected to notify the SSC of any dental needs so appointments could be scheduled and that the SSC was expected to offer annual routine dental appointments for residents.
Incomplete Oxygen Therapy Documentation and Mismatched Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for residents receiving oxygen therapy, specifically related to documentation of oxygen concentrator flow rates and accurate transcription of physician and hospice admission orders. For one resident with chronic respiratory failure with hypoxia and simple chronic bronchitis, the physician’s order dated 08/21/24 specified oxygen via nasal cannula at 1–2 LPM. However, multiple entries of oxygen saturation documentation between 12/02/25 and 12/10/25 recorded oxygen saturation values and noted use of a nasal cannula, but did not include the oxygen concentrator rate on any of the documented occasions. For another resident with COPD, chronic respiratory failure with hypoxia, a solitary pulmonary nodule, and dependence on supplemental oxygen, hospice admission orders dated 11/12/25 directed oxygen via nasal cannula at 8–10 LPM. A subsequent physician order dated 11/13/25 in the medical record instead specified oxygen via nasal cannula at 6–8 LPM for COPD, which did not match the hospice admission orders. In addition, oxygen saturation documentation for this resident from 11/17/25 to 11/30/25 repeatedly recorded oxygen saturation levels and indicated use of a nasal cannula, but on each listed entry staff failed to document the oxygen concentrator rate. A third resident with chronic respiratory failure had admission orders dated 12/05/25 for continuous oxygen starting at 2 LPM with increases as needed to keep oxygen saturation greater than 90%. A physician’s order dated the same day in the medical record instead directed to increase oxygen requirement by 2 LPM to keep oxygen saturations greater than 90%, which did not match the admission order to start at 2 LPM. Oxygen saturation documentation for this resident from 12/05/25 to 12/11/25 showed multiple entries where staff recorded oxygen saturation values and noted use of a nasal cannula, but did not document the oxygen concentrator rate. During an interview on 12/11/25, the ADON confirmed that the hospice admission orders and medical record orders for one resident did not match, the admission and medical record orders for another resident did not match, and that staff did not document oxygen concentrator rates for the three residents when documenting oxygen saturations, despite the expectation that staff correctly enter orders and document oxygen concentrator rates in the medical record.
Failure to Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident funds to the State Agency within 24 hours as required. A family member of a resident reported that shortly after the resident’s admission, he had given money to Human Resources to be placed in an account for the resident, and that a check from the resident’s previous facility was also supposed to be deposited into this account. When the family member later spoke with the Business Office Manager, he was told there was no record of the resident having a facility account or any money on file. This concern was formally documented in the facility’s Grievance Report, which stated that the family member had given the facility $140 to put into the resident’s account and that the money had disappeared. Despite this documented allegation of missing funds, a review of the State Agency’s incident reporting system showed that no incident report regarding misappropriation of this resident’s funds was submitted by the facility. In an interview, the Regional Director confirmed that the allegation of misappropriation of resident funds was not reported to the State Agency and acknowledged that the facility administrator was expected to report such allegations within 24 hours. This failure to report the allegation constituted the cited deficiency.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of misappropriation of a resident’s funds. Record review showed that the resident was admitted on an unspecified date, and the resident’s family member reported that shortly after admission he gave money to the facility’s Human Resources staff to be placed in an account for the resident. The family member also stated that a check from the resident’s previous facility was sent to the current facility and was supposed to be deposited into the resident’s account. Later, when he inquired with the Business Office Manager, he was told there was no record of the resident having a facility account or any money on file. Further record review of the facility’s Grievance Report dated 10/23/25 documented that the family member reported giving the facility $140 to place in the resident’s account and that the money had disappeared. During an interview, the Regional Director confirmed that the facility had no evidence that a thorough investigation was conducted into this allegation of misappropriation of the resident’s funds. The Regional Director also confirmed that the facility administrator was expected to conduct a thorough investigation for all allegations of misappropriation of resident property or funds, which did not occur in this case.
Inaccurate MDS Dental Assessment for Edentulous Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident’s dental status. Record review showed the resident was admitted on an unspecified date, and the family member reported that the resident had upper dentures and was missing lower dentures prior to admission. During observation and interview, the resident stated she did not have any teeth or dentures, reported she previously had dentures but was unsure what happened to them, and was observed without natural teeth or dentures. A CNA also stated the resident did not have any dentures. Despite these findings, review of the admission MDS revealed staff did not document that the resident was edentulous. The MDS Coordinator confirmed that the resident had neither her own teeth nor dentures since admission and acknowledged that the admission MDS was inaccurate because it failed to document the resident as edentulous.
Failure to Follow Physician Orders for Cardiac Medication and Hand Splint Use
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of practice for two residents. For one resident with significant cardiac conditions, including diastolic congestive heart failure, chronic atrial fibrillation, a pacemaker, and cardiomyopathy, the physician ordered amiodarone 200 mg once daily with instructions to hold the medication if the systolic blood pressure was less than 100, diastolic blood pressure less than 50, or pulse less than 60. Review of the medication administration records for April, May, and June 2025 showed that amiodarone was documented as given every morning, but there was no documentation of blood pressure readings on the MAR. Blood pressure summaries for those months showed that blood pressure was recorded only a few times (4–5 times per month) despite daily administration of the medication. The DON and the Regional Clinical Nurse both stated that the expectation was that the resident’s blood pressure should be taken and documented before administering amiodarone and confirmed that staff were not documenting that this was done. The deficiency also involves a second resident with a diagnosis of a left hand contracture. A physician order dated 10/08/25 directed that the resident wear a left modified palm guard splint daily or as tolerated. During an observation of the secured unit, the resident was not wearing the splint. One CNA reported she did not know the resident was supposed to wear a splint, and another CNA stated she had been told about the splint the previous day, recalled seeing the resident wear it in the past, but had not seen the splint or the resident wearing it for a long time and did not know where the splint was. The DON stated she did not know about the splint order and reported that the order had been discontinued the day before because the resident was not compliant with wearing the brace. Further record review for the second resident showed that the care plan dated 10/27/25 contained no documentation that the resident was non-compliant with wearing the splint. The Director of Rehabilitation stated that the splint had been ordered by an occupational therapist, confirmed the order for daily or as-tolerated wear, and reported that the order was discontinued without consultation with the occupational therapist, which she stated should have occurred. The Regional Clinical Nurse confirmed that the splint order was discontinued on 12/10/25 and stated that hospice discontinued the order and that the occupational therapist should have been consulted prior to discontinuation. These findings demonstrate that staff did not follow or appropriately manage physician and therapy orders for the resident’s splint.
Failure to Follow Foley Catheter Change Orders for Resident With Urinary Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and catheter care for a resident with significant urinary conditions. The resident was admitted with diagnoses including infection and inflammatory reaction due to an indwelling ureteral stent, calculus of the kidney and ureter, and obstructive and reflux uropathy. Physician orders dated 08/23/25 included changing the Foley catheter every 30 days, providing Foley catheter care every shift, changing the catheter as needed for leakage or drainage, and irrigating the catheter as needed. Record review showed that on 09/08/25 staff documented the resident refused a catheter change, and on 10/22/25 staff documented that the Foley catheter was changed. Further record review of the MARs for November and December 2025 revealed no documentation that the resident’s Foley catheter was changed during those months. An LPN stated that Foley catheters are typically changed every 30 days and acknowledged that the order for a 30‑day catheter change had been incorrectly entered and automatically discontinued on 09/09/25, resulting in the catheter being changed only once since 08/23/25. The ADON confirmed that Foley catheters should be changed every 30 days unless otherwise ordered, that the resident’s 30‑day catheter change order was incorrectly entered and discontinued, and that the catheter was only changed once on 10/22/25, despite expectations that staff ensure Foley catheters are changed as ordered.
Lack of Hospice Documentation and Coordinated Care Plans for Hospice Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure hospice services met professional standards for two residents receiving hospice care by not maintaining hospice documentation or a coordinated plan of care. One resident with a diagnosis of senile degeneration of the brain had a physician’s order for hospice admission, but the medical record contained no documentation from hospice staff regarding services provided and no coordinated plan of care delineating which services hospice was responsible for and which the facility was responsible for. The hospice binder at the nurse’s station also lacked any documentation of hospice services or a coordinated care plan for this resident. An LPN reported that the hospice provider did not give the facility documentation of services, that she had not seen a coordinated care plan, and that she was unsure which days hospice staff were expected to see the resident or what services hospice versus facility staff were supposed to provide. The ADON confirmed that hospice documentation and a coordinated care plan should have been available in the hospice binder or the resident’s record, but none existed, and stated that the hospice provider did not provide documentation regarding services for this resident. A second resident with COPD was also admitted to hospice services per physician order, but the resident’s medical record contained no documentation from hospice staff regarding services provided. The ADON confirmed that this hospice provider did not provide documentation of care, that if hospice staff did not speak directly with facility staff the facility would not know what services were provided, and that staff had no documentation to review to determine what hospice services had been delivered. The medical records clerk confirmed that the hospice provider did not provide any documentation for either resident, despite the expectation that hospice providers submit visit notes after each visit so they could be scanned into the medical record and placed in the hospice binder. The Regional Clinical Nurse confirmed that each hospice resident should have a coordinated care plan delineating hospice versus facility responsibilities, that staff should know where to locate it, and that hospice staff are expected to provide documentation every time they visit a resident.
Failure to Ensure Safe and Compatible Bed Rail Installation
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that a bed rail and bed were compatible and safely installed for one resident reviewed for accidents. During observation, the resident was seen in bed with a bed rail that was loose and moved side to side approximately 1 to 2 inches along the length of the bed; the rail appeared to be an aftermarket attachment to the bed frame. When the resident reached for the rail to assist with getting up from a lying position, the rail gave way. Review of the resident’s medical record showed no documentation that the bed rail had been inspected for proper installation. In an interview, the ADON confirmed that the bed rail was not sturdy and stated she did not know if the bed rail had been inspected for proper installation. This sequence of events demonstrates that the facility did not perform or document inspection of the bed rail and its attachment to the bed frame, resulting in the presence of a loose, aftermarket bed rail used by the resident for mobility assistance.
Staff Negligence and Abuse Incident
Penalty
Summary
The facility failed to protect residents from abuse and neglect when a staff member, identified as CNA #1, exhibited multiple inappropriate behaviors during his shift. CNA #1 frequently left the building to go to his car, wore air pods in both ears, and fell asleep on the unit couch during the dinner meal. These actions prevented him from adequately attending to the residents' needs and created an environment where residents could feel unsafe. Additionally, CNA #1 used loud, foul, and abusive language, further contributing to the unsafe atmosphere. On the day of the incident, CNA #1 arrived late for his shift and was observed by multiple staff members to be neglecting his duties. He did not assist with resident care, such as helping residents get up, changing briefs, or providing showers. Instead, he was seen frequently going to his car and using his phone. CNA #1 was also reported to have smelled of alcohol, and after being woken up from sleeping on the couch, he became belligerent, cussed at staff, and threatened to harm them. The situation escalated to the point where the police were called, and they found alcohol bottles in his car. The incident was witnessed by residents and staff, causing distress and fear among those present. The facility's staff, including RN #1 and the Scheduler, were aware of CNA #1's behavior but did not take immediate action to remove him from the facility until the situation had escalated. The delay in addressing the issue and the failure to protect residents from CNA #1's behavior resulted in a deficiency in the facility's obligation to ensure a safe and abuse-free environment for its residents.
Delayed Reporting of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency within the required two-hour timeframe for 25 residents on the secure unit and north hall. The incident involved CNA #1, who was found asleep on the job, smelled of alcohol, and became belligerent, threatening staff and exhibiting aggressive behavior. The incident occurred on 10/18/24, but the report was not submitted until 10/25/24. Multiple staff members, including RN #1 and the Scheduler, observed CNA #1's inappropriate behavior, which included yelling profanities and threatening to harm staff. Residents in the common area and North Hall witnessed the altercation, which created a threatening environment. The incident report revealed that CNA #1 was a traveling CNA working his first shift at the facility. He was late for his shift, did not assist with resident care, and frequently left the facility to go to his car. RN #1 and the Scheduler both reported concerns about CNA #1's behavior, including his use of air pods and frequent absences from the unit. Despite these concerns, the incident was not reported to the State Agency in a timely manner, delaying potential corrective actions and leaving residents exposed to potential harm.
Deficiency in Abuse, Neglect, and Exploitation Training for Agency CNA
Penalty
Summary
The facility failed to provide abuse, neglect, and exploitation (ANE) training to a certified nursing assistant (CNA) from an outside agency, identified as CNA #1, before they began working with residents. CNA #1 was hired on 10/18/24 and started working with residents on the same day without completing the required ANE training. The facility's Director of Nursing (DON) confirmed that agency staff were not required to complete ANE training with either the outside agency or the facility before working directly with residents. Additionally, the Human Resources (HR) department did not have an employee file for CNA #1 and did not verify with the agency whether CNA #1 had completed the necessary ANE training. The HR department assumed that the outside agency would ensure their staff met all state and federal training requirements, but they did not contact the agency for proof of CNA #1's training completion. This oversight was compounded by the fact that agency staff sometimes only work one shift, making it challenging to ensure they complete the required trainings before working with residents. The lack of documentation and verification of ANE training for CNA #1 represents a significant deficiency in the facility's training and onboarding processes for agency staff.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, impacting all 43 residents who consumed food prepared in the kitchen. During an observation, it was noted that a bag of chicken nuggets in the refrigerator was neither labeled with an open date nor properly sealed, as it was merely rolled closed and had unrolled, leaving it open. This was confirmed by the Lead, who acknowledged that the staff should have sealed and dated the opened bag of chicken nuggets. Additionally, the facility did not manage its spices according to safety standards. Expired seasonings, including parsley and basil, were found in the kitchen. Furthermore, several open containers of spices, such as chili powder, ground thyme, ground coriander, Italian seasoning, granulated onion, and vanilla extract, lacked expiration or use-by dates. The Lead confirmed that these spices were expired and should have been discarded, and that staff were expected to date the seasonings upon opening to track their age.
Deficiency in Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically lacking a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water system. This deficiency could potentially affect all 43 residents living in the facility. The facility's Water Management Program for Building Water Systems, dated 2019, indicated that the administrator was responsible for overall compliance, while the Environmental Services Director or designee was responsible for implementation and daily operations. However, the Site Management Plan section identifying responsible team members was left blank. Interviews with facility staff revealed a lack of awareness and responsibility regarding the water management program. The DON, responsible for infection prevention, admitted to not completing any assessments or prevention measures for Legionella or waterborne pathogens and was unaware of who was responsible for water management. The Maintenance Worker, who had been with the facility for four years, and the Environmental Services Director for Housekeeping and Laundry both confirmed they were unaware of any water management program, lacked a map or diagram of the water system, and did not know where Legionella or other pathogens could grow. The DON also confirmed that the Water Management Plan did not list any team members as part of the Program Management Team, and she could not identify staff responsible for water management tasks.
Failure to Provide Prescribed Supplement
Penalty
Summary
The facility failed to ensure pharmaceutical services were adequately provided for a resident, leading to a deficiency in medication management. A physician's order dated June 27, 2024, required the administration of a 1500 mg turmeric tablet daily as a supplement for the resident. However, the Medication Administration Record (MAR) for August 2024 indicated that the medication was unavailable from August 14 to August 28, 2024. During an interview, a Certified Medication Aide (CMA) stated that the turmeric was not available because the resident's family did not supply it to the facility. There was no documentation of communication with the pharmacy or the resident's family regarding the unavailability of the turmeric. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged the facility's responsibility to ensure the resident received the prescribed supplement.
Deficient Care Plans for Residents
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for two residents, which could result in staff being unaware of the residents' current and actual needs. For one resident, the care plan did not include necessary interventions for managing oxygen dependency and pain management. The resident had multiple diagnoses, including fibromyalgia, osteoarthritis, and chronic obstructive pulmonary disease, and was prescribed oxygen therapy and pain medications. However, the care plan lacked specific actions for assessing and monitoring the resident's oxygen use and pain management, as confirmed by the Director of Nursing (DON). Another resident's care plan was deficient in documenting the reason for the use of antipsychotic medication and lacked measurable objectives. This resident had diagnoses including Alzheimer's disease, unspecified dementia, and major depressive disorder, and was prescribed Seroquel for dementia with irritability. The care plan stated the resident would have positive results from the medication but did not specify what outcomes would indicate positive results. The DON confirmed that the care plan did not include the reason for the antipsychotic medication or measurable objectives. These deficiencies highlight the facility's failure to provide comprehensive care plans that address the specific needs and conditions of the residents. The lack of detailed interventions and measurable objectives in the care plans could lead to inadequate care and monitoring of the residents' health conditions.
Failure to Update Care Plan for Lost Dentures
Penalty
Summary
The facility failed to revise the care plan for a resident who lost her lower dentures. During an interview, the resident mentioned she had lost her bottom dentures but could not recall when this occurred. A review of the resident's progress notes from June indicated she wore full dentures, yet her care plan from later that month did not reflect the loss of her bottom dentures. Interviews with the Business Office Manager and the Director of Nursing confirmed the dentures were missing, and it was acknowledged that the care plan should have been updated to reflect this change.
Failure to Administer Blood Pressure Medication per Physician Orders
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of blood pressure medication for one resident. The resident had physician orders for amlodipine besylate and lisinopril, both to be held if the systolic blood pressure (SBP) was less than 100. However, on multiple occasions, the staff did not administer the medication despite the SBP not being below the specified threshold. Specifically, on July 15, 2024, the resident's blood pressure was recorded as 107/62, and on July 16, 2024, it was 102/53, yet the medication was held without further documentation of additional blood pressure readings. The Director of Nursing (DON) confirmed that the staff did not follow the physician's orders, as there was no documentation of a systolic blood pressure less than 100 on the dates the medication was withheld. Additionally, there were no blood pressure readings documented at the time the medication was held, which was against the facility's expectations. This lack of adherence to the specified parameters for medication administration could potentially lead to adverse effects for the resident.
Failure to Maintain Resident's Functional Abilities Post-Injury
Penalty
Summary
The facility failed to maintain or improve the functional abilities of a resident, identified as R #12, who was admitted with multiple diagnoses including unspecified dementia, Alzheimer's disease, and a history of falling. The resident's quarterly MDS assessment indicated that she required supervision or partial/moderate assistance with various activities of daily living (ADLs). However, after a fall resulting in a fracture of the distal radius and ulna, her functional abilities significantly declined, requiring substantial/maximal assistance for all ADLs. Despite the resident's fracture healing, as indicated by the physician's orders and x-ray reports, the facility did not implement a restorative nursing program or refer the resident for therapy to help her regain her prior level of functioning. Interviews with staff, including a CNA, the MDS coordinator, and a Certified Occupational Therapy Assistant, revealed that no restorative nursing or therapy evaluation was conducted after the resident's wrist healed. The staff acknowledged that the resident was functional with her left wrist for several weeks, yet no actions were taken to address her decreased functional abilities. The lack of a restorative nursing program and failure to refer the resident for therapy evaluation after her fracture healed contributed to the deficiency. The facility did not ensure that the resident's ability to perform ADLs was maintained or improved, leading to a continued need for substantial/maximal assistance in her daily activities. This oversight highlights a gap in the facility's care planning and follow-up processes for residents with changing medical conditions.
Failure to Provide Ordered Restorative Rehabilitation Services
Penalty
Summary
The facility failed to provide restorative rehabilitation services as ordered by the physician for two residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Resident #9 was discharged from physical and occupational therapy with a ROM program in place for the right upper extremity. However, during interviews, it was revealed that the resident did not receive any formal therapy services, although nurses assisted with movement. The Certified Nursing Assistant (CNA) involved stated she performed ROM exercises with the resident but was unsure if this was documented. The Director of Nursing (DON) confirmed the absence of a restorative program, and the Minimum Data Set Coordinator (MDSC) acknowledged the lack of documentation for ROM exercises. Similarly, Resident #37 was discharged with instructions for bilateral upper extremity therapy exercises at the bedside. The resident reported receiving assistance from nurses for exercises, but like Resident #9, there was no documentation of ROM exercises being performed by the CNAs. The CNA confirmed performing ROM exercises but was uncertain about documentation. The DON reiterated the lack of a restorative program, and the MDSC confirmed the absence of documentation. Additionally, the Certified Occupational Therapy Assistant (COTA) stated that CNAs were not instructed on how to perform ROM exercises, further contributing to the deficiency.
Inappropriate Use of Antipsychotic Medication for Dementia
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medications unless necessary to treat a specific psychiatric diagnosis. This deficiency was identified for one resident, who was prescribed Seroquel, an antipsychotic medication, for dementia with irritability/agitation/aggression. The record review revealed that the resident had multiple diagnoses, including Alzheimer's disease, unspecified dementia, neurocognitive disorder with Lewy bodies, major depressive disorder, generalized anxiety, and other specified anxiety disorder. However, dementia was not an appropriate diagnosis for the use of Seroquel, as confirmed by the Director of Nursing (DON). The physician's order for Seroquel included a black box warning from the FDA, indicating an increased risk of mortality in elderly patients with dementia-related psychosis when treated with antipsychotic drugs. Despite this warning, the resident was prescribed Seroquel without an appropriate diagnosis, which could lead to unnecessary medication use and increased risk of adverse side effects. The DON confirmed that the expectation was for residents prescribed antipsychotic medication to have an appropriate diagnosis, which was not met in this case.
Improper Medication Storage in East Unit
Penalty
Summary
The facility failed to properly store medications for all 17 residents in the East Unit, as identified by the Resident Matrix provided by the Administrator. During an observation of the medication cart assigned to the East Unit, a white round tablet was found loose in the second drawer of the cart, located towards the back of the medication cards. This observation was made on 08/28/24 at 12:05 PM. Subsequently, at 12:06 PM, CMA #24 confirmed that the white round tablet was loose and not contained in a bubble pack or pill container. This deficiency in medication storage could potentially lead to residents obtaining or being administered medication not prescribed to them, receiving medications that are less effective, and experiencing adverse side effects.
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Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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