Spanish Trails Rehabilitation Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 1610 N Renaissance Blvd Ne, Albuquerque, New Mexico 87107
- CMS Provider Number
- 325131
- Inspections on file
- 41
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Spanish Trails Rehabilitation Suites during CMS and state inspections, most recent first.
Two residents experienced medication-related deficiencies when staff failed to follow professional standards for medication availability, administration, and monitoring. One resident with an order for Jardiance to control blood sugar had the drug marked as given on the MAR on several days even though it was not available and not administered, while an LPN checked the resident’s blood sugars without a physician’s order and did not document the results. Another resident with a history of cerebral infarction and hemiplegia had multiple ordered warfarin doses missed, and the DON later confirmed the missed doses and stated she had not been informed that the high-risk medication had not been given as ordered.
A resident with multiple medical conditions, including osteoporosis, epileptic spasms, GERD, post-stroke hemiplegia/hemiparesis, insomnia, and recurrent major depressive disorder, did not receive an accurate MDS assessment when the BIMS cognitive interview was omitted on a scheduled assessment. A prior MDS had documented a BIMS score of 15, but the later assessment lacked any BIMS evaluation. The MDS coordinator confirmed that this assessment was completed remotely rather than in person and acknowledged that the absence of the BIMS made the MDS inaccurate.
A resident admitted with hemiplegia following a cerebral infarction, generalized muscle weakness, need for assistance with personal care, and chronic migraine had physician orders for low-dose aspirin for clot prevention and warfarin for cerebral infarction. The baseline care plan, completed after admission, noted full code status, fall risk related to psychotropic use, poor balance and weakness, and potential for pain, but did not address the resident’s anticoagulant therapy. In an interview, the DON confirmed that the baseline care plan omitted anticoagulant use and was not completed within the required 48-hour timeframe.
A resident was admitted with multiple diagnoses, including osteoporosis, epileptic spasms, GERD, hemiplegia/hemiparesis after cerebral infarction, insomnia, recurrent major depressive disorder, dementia, and a need for ADL assistance. Review of the care plan showed it only addressed elopement risk, dementia-related nutritional risk, and behavior changes after stroke, while omitting other significant conditions such as epileptic spasms, GERD, insomnia, depression, and ADL needs. During interview, the DON confirmed these omissions and acknowledged that the care plan was not person-centered and did not reflect the resident’s overall condition.
A resident with a history of CVA, falls, poor safety awareness, and cognitive impairment, whose care plan called for frequent observation and supervised placement when out of bed, was transported alone to a follow-up medical appointment and left unattended. Family members reported that the physician’s office called them expressing concern about the resident’s safety and that the resident was found sitting in a wheelchair without having been seen by the doctor. Transport staff stated they were trained that drivers only provide transportation and no patient care, and that they rely on the DON’s notation on the appointment sheet to know if an escort is needed. An LPN reported that not all residents go to appointments with escorts and that the scheduler would know if an escort was required, and she was unaware that this resident had been left alone.
A resident with hemiplegia and hemiparesis following a cerebral infarction, along with other conditions including generalized muscle weakness and chronic migraine, had multiple changing physician orders for warfarin to treat cerebral infarction affecting the left dominant side. Review of the MAR showed that three ordered doses of warfarin were not administered, and in an interview the DON confirmed the missed doses, acknowledged that warfarin is a high-risk medication that must be given as ordered, and stated she had not been informed of the missed doses or any medication unavailability.
A resident with a history of aggression and multiple behavioral health diagnoses was involved in a physical altercation with a CNA after staff failed to follow the resident's request and lacked appropriate de-escalation training. The incident resulted in the resident falling and sustaining an injury, highlighting the facility's failure to provide necessary behavioral health care and adequate staff training to manage aggressive behaviors.
A resident with complex medical needs did not receive weekly skin assessments as ordered, resulting in missed documentation and the development of a stage 2 pressure ulcer. Additionally, there was a significant delay in obtaining a physician's order and completing a swallow study after repeated recommendations by the SLP, due to poor communication between nursing and therapy staff.
Two residents who were dependent on staff for toileting and incontinent care did not receive timely brief changes, with documentation and staff interviews confirming that one resident went an entire shift without assistance and another was changed only one or two times per day despite frequent incontinence and skin breakdown.
A resident with significant care needs, including incontinence and dependence on staff for toileting, was left without assistance throughout an overnight shift. Documentation and investigation confirmed that the resident was not provided care, was left in a soiled brief, and call light requests were ignored by a CNA, resulting in substantiated neglect.
A resident with multiple chronic conditions was left without care by a CNA for most of a 12-hour shift. Although the administrator initiated an investigation by phone, there was no written documentation of interviews or follow-up actions, resulting in a deficiency for failure to document the investigation.
A resident admitted with heart failure, Parkinson's disease, and respiratory failure did not have a comprehensive care plan developed during their stay. Although an initial care plan and some updates were present, a full comprehensive care plan was not completed, as confirmed by the interim DON after reviewing the medical record.
A resident with GERD, diabetes, and other conditions did not receive medications with meals as ordered by a physician. The resident reported a preference for taking medications with food to reduce stomach irritation, but an LPN considered the order outdated and did not follow it after the resident's hospital stay, resulting in the resident not receiving medications as ordered.
The facility did not consistently protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
Two residents experienced significant financial losses due to unauthorized use of their debit cards, with one losing $1,300 after hospitalization and another discovering $23,000 missing from his account. Facility staff failed to promptly report or investigate the incidents, and did not assist in obtaining necessary documentation, allowing the misappropriation to go undetected.
A resident with multiple serious health conditions was transferred to the hospital several times due to changes in condition, but the provider and emergency contact were not notified as required. Documentation and staff interview confirmed the lack of communication regarding these hospital transfers.
Staff did not conduct required quarterly care plan meetings for several residents, resulting in overdue reviews and updates of care plans. Additionally, a resident's care plan was not updated to reflect that the resident and family were providing colostomy care, despite staff and family confirming this arrangement.
Staff did not ensure proper labeling, dating, and storage of food items, with several foods found unlabeled, undated, left open to air, or stored past expiration in the kitchen and dry storage. The Dietary Manager confirmed these lapses, which affected all residents in the facility.
A resident developed a sore and redness near the right eye, reported pain, and stated that nursing staff had not examined the area. The DON was unaware of the issue, and review of shower sheets showed no documentation or assessment of the skin condition, despite facility protocols requiring such actions.
A nurse entered a bathroom without announcing herself while a resident was being assisted with a shower by a CNA, resulting in the resident feeling that her privacy and dignity were not respected. The resident, who is cognitively intact and requires significant assistance with bathing, expressed that the unannounced entry made her uncomfortable, and this was confirmed by her roommate. Facility staff acknowledged that the expected protocol is to knock and announce before entering during personal care, but this was not followed in this instance.
A resident with multiple complex diagnoses was transferred to the hospital after exhibiting significant changes in condition, including reduced strength and slurred speech. The facility completed required MDS discharge and entry assessments but did not complete a significant change in status assessment within the required timeframe. The DON and MDS coordinator were unsure if this assessment was needed.
A resident on Warfarin experienced an unwitnessed fall, but facility staff did not immediately notify the provider or the resident's emergency contact. The incident was only documented later, and the family learned of the fall after visiting. The resident, with a history of fractures, developed new symptoms and was later found to have rib fractures after being sent to the hospital by family. Staff interviews confirmed that required notifications were not made.
A resident was repeatedly administered oxygen therapy without a physician's order, as confirmed by documentation in the EHR and interviews with staff and the emergency contact. The DON verified that no order was present despite frequent oxygen use.
A resident with specific dietary restrictions and preferences was repeatedly served foods she could not eat, such as vegetables and mashed potatoes, despite clear instructions on her meal ticket. Staff interviews and meal observations confirmed that her dietary needs were not being followed.
A resident's grievance regarding cold meals, hair in food, and delayed CNA assistance was inadequately investigated by the facility. The Social Services Director only addressed the food temperature issue without taking actual measurements and ignored other concerns. The resident remained dissatisfied, and the Administrator admitted the grievance was not properly resolved.
The facility failed to conduct timely care plan meetings for two residents, resulting in outdated care plans. One resident had their last meeting in July and could not recall a recent meeting, while another expressed a desire for a meeting. The Social Services Director confirmed that both residents were overdue for quarterly care plan meetings, indicating a failure to update and address their care needs.
The facility failed to communicate critical lab results timely and ensure medication availability for two residents. One resident's critical lab results were not conveyed to the provider promptly, delaying medical intervention. Another resident did not receive their prescribed Eliquis due to unavailability, and the nurse did not check the Pyxis or notify the provider.
A facility experienced a medication error rate of 23.08% due to the unavailability of Eliquis for a resident, despite it being prescribed for daily administration. RN #2 administered other medications as ordered, but the failure to provide Eliquis contributed to the high error rate. The ADON confirmed that medications should be administered within a specific timeframe, and deviations are considered late.
The facility failed to serve meals at safe temperatures, affecting four residents who reported receiving cold food despite complaints. Observations showed food on the steam table was below safe temperatures due to a malfunctioning steam table. Staff interviews confirmed the issue, and a resident had filed a grievance about the cold meals.
A facility failed to ensure proper infection control practices during medication administration when an RN did not wash his hands before, during, or after administering medications to two residents. The RN admitted to not using the hand wash stations available in the resident rooms, and the DON confirmed that staff should wash hands before and after medication administration.
A resident was not assisted with purchasing painting materials and winter clothes after the departure of the previous SSD who used to help with these purchases. The resident, who enjoys activities like painting and reading, repeatedly asked facility staff for assistance but did not receive help. The facility administrator confirmed the oversight.
A resident who followed a vegan diet was admitted to the facility with a regular diet order. Despite informing staff of her vegan preference, she continued to receive non-vegan meals. The absence of the Kitchen Manager, who typically conducted dietary preference interviews, led to a lack of communication and follow-up, resulting in the resident not receiving appropriate meals.
A resident was not provided with the prescribed therapeutic diet, receiving mechanical soft meatloaf instead of the ordered pureed diet. This discrepancy was confirmed by dietary staff, highlighting a failure to adhere to the physician's dietary orders.
A resident did not receive necessary assistance with toileting and brief changes, as staff failed to enter the room throughout the day. The resident's daughter discovered this through an in-room camera. The CNA responsible admitted to not checking on the resident during her shift, leading to the CNA's dismissal.
A resident in an LTC facility experienced worsening pressure ulcers due to inadequate monitoring and communication. Staff failed to identify and document the resident's pressure ulcers upon admission and did not update treatment orders or notify the physician of the worsening condition. The resident's ulcers progressed to stage 4, leading to hospitalization and hospice care. Interviews revealed a lack of communication and documentation among staff regarding the resident's deteriorating condition.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including improper maintenance of ice machines, inadequate hand hygiene and glove use by staff, and failure to protect clean dishes from contamination. Additionally, pureed food was not served at appropriate temperatures, and there were issues with labeling and storing food items. The kitchen environment was not maintained in a clean manner, posing potential risks to residents.
The facility failed to update care plans for two residents regarding ADL needs and activity preferences, and did not inform a resident's POA about changes in behavioral symptoms. The DON and Activities Director confirmed these omissions, which could lead to unmet care needs.
Two residents in an LTC facility did not receive the scheduled number of baths or showers due to staff shortages. One resident, requiring partial assistance, often received only one shower a week, while another, needing maximal assistance, also missed scheduled bathing. Staff confirmed the deficiency, and the DON acknowledged the failure to meet care plans.
A facility failed to ensure medications were not left unattended on a resident's bedside table, posing a risk to residents on the 400 hall. During an observation, 12 pills were found on a bedside table, including Ranolazine, Mucus Relief DM, and Pantoprazole Sodium. Interviews with staff revealed that a CMA left the medications there, contrary to protocol requiring staff to observe residents taking their medications.
The facility failed to ensure staff followed nutritionally calculated recipes for pureed diets, affecting six residents. Staff did not measure ingredients accurately or follow recipes, as observed during meal preparation. The Dietary Manager admitted to not following a recipe due to time constraints and lack of awareness. The Registered Dietician confirmed that recipes are reviewed every six months and expected staff adherence.
The facility failed to follow infection control practices for four residents. Nasal cannulas were not labeled with change dates, and CPAP equipment and nebulizers were improperly stored. Staff interviews confirmed these lapses, which could lead to infection spread.
A resident who required a sippy cup for meals did not receive one, despite recommendations and physician orders. During a meal observation, the resident was served without the necessary device, and an LPN confirmed its absence.
The facility failed to honor a resident's rights by administering medication to reduce sexual desires without proper consent. Despite a psychologist's assessment that the resident could consent to sexual activity, the NP and Medical Director increased the resident's escitalopram dosage to dampen libido, citing concerns about decisional capacity.
A resident with multiple diagnoses, including vascular dementia and mood disturbance, was administered an increased dose of escitalopram without adequate indications. The increase was recommended to dampen the resident's libido following a sexual incident, despite no documented increase in depression. The Medical Director and Nurse Practitioner acknowledged the resident's inability to make informed decisions, yet the resident was his own decision maker.
Failure to Follow Professional Standards in Medication Availability, Administration, and Monitoring
Penalty
Summary
The deficiency involves failures to meet professional standards of quality in medication management and monitoring for two residents. For one resident with an order dated 12/16/25 for Jardiance 10 mg orally once daily to control blood sugar levels, the MAR from 01/29/26 through 02/06/26 showed the medication as administered on multiple dates (01/30/26, 01/31/26, and 02/04/26 through 02/06/26) despite the medication not being available. A CMA stated that the last actual dose was given on 01/28/26 and confirmed that she documented the medication as given on 01/30/26, 01/31/26, and 02/06/26 even though it was not available and not administered. An RN and an LPN both confirmed that the Jardiance had not been available since late January and that the resident had not been receiving it since that time. The LPN further reported that she had been checking the resident’s blood sugars without a physician’s order, was not documenting those blood sugar results in the chart, and was using the information only for her own reference. For another resident admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura, multiple warfarin dose changes were ordered over January 2026 for treatment of cerebral infarction affecting the left dominant side. Review of the January MAR showed that this resident missed warfarin doses on 01/18/26, 01/19/26, and 01/21/26. The DON confirmed that these warfarin doses were missed, acknowledged that warfarin is a high-risk medication that should be given as ordered, and stated she had not been aware that any doses were missed. The DON also stated she expects nurses to notify her and the pharmacy when medications are not available.
Inaccurate MDS Assessment Due to Omitted BIMS Evaluation
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident when the Brief Interview for Mental Status (BIMS) was not conducted as required. The resident had been admitted with multiple diagnoses, including age-related osteoporosis without current pathological fracture, epileptic spasms without status epilepticus, GERD without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified insomnia, recurrent moderate major depressive disorder, and a need for assistance with personal care. Record review showed that on a prior MDS dated 09/16/25, the resident’s BIMS score was documented as 15, indicating that a cognitive assessment had been completed at that time. However, review of the subsequent MDS dated 12/17/25 revealed that the resident was not assessed for BIMS at all. During an interview, the MDS coordinator confirmed that this assessment did not include an in-person evaluation and acknowledged that the MDS was completed remotely for this particular assessment. She further confirmed that the omission of the BIMS assessment made the MDS inaccurate, as the resident should have been assessed in person and the BIMS completed as part of the federally mandated assessment process.
Failure to Include Anticoagulant Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura. Physician orders for this resident included low-dose aspirin for clot prevention and warfarin sodium for cerebral infarction. The baseline care plan, dated several days after admission, documented that the resident had an advance directive of full code, was at risk for falls related to psychotropic medication use, poor balance, and weakness, and had potential for pain. However, the baseline care plan did not address the resident’s use of anticoagulant medication, despite active orders for aspirin and warfarin. During an interview, the DON confirmed that the baseline care plan did not include the use of anticoagulants and acknowledged that the baseline care plan should have been completed within 48 hours of admission, which did not occur.
Failure to Develop Comprehensive, Person-Centered Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan for one resident. Record review showed the resident was admitted with multiple diagnoses, including age-related osteoporosis without current pathological fracture, epileptic spasms not intractable and without status epilepticus, GERD without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified insomnia, recurrent moderate major depressive disorder, and a need for assistance with personal care. These conditions were pertinent to the resident’s care needs. Review of the resident’s care plan dated 01/21/26 revealed it addressed only certain issues: risk for elopement related to an elopement evaluation risk score, dementia placing the resident at risk for altered nutritional status, and a history of stroke affecting behavior with a tendency to make demands and inappropriate comments to staff. The care plan did not address other documented conditions such as epileptic spasms, GERD, cerebral infarction-related deficits, insomnia, major depression, and ADL needs. In an interview, the DON confirmed that these conditions were not included in the care plan and acknowledged that the plan was not person-centered and did not reflect the resident as a whole.
Failure to Provide Escort and Supervision for High-Risk Resident at Medical Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents when a resident with a history of falls and cognitive impairment was sent alone to a follow-up medical appointment. The resident had a history of cerebrovascular accident (CVA), poor safety awareness, and a tendency to move independently without using the call light or setting wheelchair brakes. The resident’s care plan, dated 09/27/25, included interventions such as more frequent visual rounding, offering frequent help as needed, and placing the resident in supervised areas when out of bed. Despite this, the resident was transported to a doctor’s appointment without an escort and was left unattended for an extended period. The resident’s brother reported receiving a call from the doctor’s office asking who was supposed to pick the resident up and expressing concern for his safety, and he stated that the facility did not respond when he called to ask why the resident was left alone. The resident’s sister stated that due to his cognitive ability he could not be left alone, that the facility had assured her he would not be left alone, and that he was found sitting in a wheelchair with a paper and likely was not seen by the doctor because he was alone and unable to care for himself cognitively. The central supply/transport driver stated she was not aware the resident needed someone to go with him and explained that the process relied on the DON marking the appointment sheet if an escort was required; she also stated they had been trained that drivers do not stay at appointments and provide no patient care. An LPN stated that not every person going to an appointment has an escort and that the person scheduling appointments would know if an escort was needed, and she was not aware of this resident being left alone at his appointment.
Missed High-Risk Warfarin Doses for Anticoagulation Therapy
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors involving the anticoagulant warfarin. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura. Physician orders showed multiple adjustments to the resident’s warfarin regimen over time, including varying dosages and schedules (daily dosing, then specific days of the week, and later a fixed daily dose) for treatment of cerebral infarction affecting the left dominant side. Record review of the January 2026 MAR revealed that three ordered doses of warfarin were not administered on 01/18/26, 01/19/26, and 01/21/26. During an interview, the DON confirmed that these warfarin doses were missed and acknowledged that warfarin is a high-risk medication that should be administered as ordered. The DON also stated she had not been aware that the resident had missed any warfarin doses and reported that her expectation is that nurses notify her and the pharmacy if a medication is not available.
Failure to Provide Necessary Behavioral Health Services and Staff Training
Penalty
Summary
The facility failed to ensure that a resident with a history of aggressive behaviors received the necessary behavioral health care and services to maintain their highest practicable well-being. The resident, who had diagnoses including cognitive communication deficit, depression, and a history of physically abusive behavior, was involved in an incident where he attacked a CNA, resulting in a fall and injury. The care plan for the resident identified aggressive and abusive behaviors, but interventions were limited to psychosocial therapy, 1:1 oversight as needed, and general support for anxiety and depression, without specific strategies for staff to manage or de-escalate aggressive incidents. On the night of the incident, the resident became upset after a wound dressing was changed and additional staff entered his room, which he perceived as threatening. Despite the resident's request for a particular CNA to leave, the CNA remained and attempted to provide care, leading to a physical altercation. The resident reported feeling provoked and acted in self-defense, resulting in a struggle and subsequent fall. Staff interviews confirmed that the resident was known for aggressive behavior and had a prior negative interaction with the CNA involved in the incident. The facility did not provide staff with de-escalation or specialized training for managing aggressive behaviors prior to the incident. Staff received only general abuse and neglect training upon hire, and there were no documented interventions or training in place to address the specific behavioral health needs of residents exhibiting aggression. This lack of appropriate staff training and tailored interventions contributed to the escalation of the situation and the resulting injury.
Failure to Follow Physician Orders for Skin Assessments and Timely Swallow Study
Penalty
Summary
The facility failed to provide quality care that meets professional standards for a resident with multiple diagnoses, including metabolic encephalopathy, dysphagia, moderate malnutrition, weakness, and dementia. Staff did not follow physician orders for weekly skin assessments, as evidenced by gaps in documentation and missed assessments over several weeks. The resident developed a stage 2 pressure ulcer and had ongoing skin issues, but weekly assessments were not consistently completed as ordered. Both a registered nurse and the interim director of nursing confirmed that the weekly skin assessments were not performed as required by the physician's orders. Additionally, the facility did not obtain a physician's order and complete a swallow study in a timely manner after it was recommended by the speech language pathologist (SLP). The SLP documented several recommendations for a swallow study over multiple weeks before an order was finally placed and the study was completed. Interviews with the SLP and the interim director of nursing confirmed that the delay was due to a lack of timely communication and follow-through between nursing staff and therapy, resulting in a significant delay in addressing the resident's swallowing difficulties.
Failure to Provide Timely Brief Changes and Daily Care
Penalty
Summary
The facility failed to provide adequate daily care, specifically timely brief changes, for two of three residents reviewed for care needs. One resident, who was dependent on staff for toileting and dressing due to conditions such as Parkinsonism and acute respiratory failure, had no documentation of assistance with toileting or brief changes during an entire evening shift. The Interim Director of Nursing confirmed that the resident's brief should have been changed during that time. Another resident, who had moisture-associated skin damage and was care planned for frequent brief checks and changes every two hours, was documented as having her brief changed only one or two times per 24 hours over multiple days. Skin assessments revealed the development of a stage 2 pressure ulcer and ongoing redness in the groin area. Interviews with the resident's son, CNAs, and RNs confirmed that the resident was not changed as frequently as required, and that this lack of care contributed to skin breakdown.
Failure to Provide Nighttime Care and Assistance
Penalty
Summary
A resident with multiple diagnoses, including Parkinsonism and acute respiratory failure with hypoxia, was admitted to the facility and required assistance with self-care, mobility, and was dependent on staff for toileting and dressing due to incontinence. The resident's care plan included encouragement to use the call light, monitoring for pain, and provision of medication as needed. On the night in question, there was no documentation of care provided by any CNA from the evening through the following morning, indicating that the resident did not receive assistance with toileting or brief changes during the entire shift. An incident report and subsequent investigation confirmed that a CNA failed to provide care to the resident throughout the night, leaving the resident in a urine-soaked brief and not responding to the call light. The neglect was substantiated by the facility's investigation, and the administrator confirmed being notified of the incident and verified the neglect occurred during the specified shift.
Failure to Document Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly document the investigation of an alleged neglect incident involving a resident with diagnoses including heart failure, Parkinson's disease, and respiratory failure. The incident involved a Certified Nurse's Aide (CNA) who was reported to have provided no care to the resident during a 12-hour overnight shift, leaving the resident in her room for most of that period. The administrator was notified of the incident and began an immediate investigation by contacting staff by phone. Despite initiating an investigation, the administrator did not provide any written documentation of the interviews conducted, the investigation process, or any follow-up training related to the incident. The only documentation available was a follow-up report summarizing the incident, with no supporting evidence or records of staff interviews or retraining. This lack of thorough documentation led to the deficiency cited in the report.
Failure to Develop Comprehensive Care Plan After Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident following their admission. Record review showed that the resident was admitted with diagnoses including heart failure, Parkinson's disease, and respiratory failure. The Minimum Data Set (MDS) 5-day admission assessment was completed and signed by the MDS RN, but a review of the electronic medical record for the resident's stay did not reveal a comprehensive care plan. Only an initial care plan and some additions were found, but no complete comprehensive care plan was documented. The interim Director of Nursing confirmed that, despite reviewing the care plan and electronic medical record, a comprehensive care plan had not been completed for the resident.
Failure to Follow Physician Order for Medication Administration with Meals
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for a resident with multiple diagnoses, including GERD, cognitive communication deficit, type 2 diabetes mellitus, and generalized anxiety disorder. The physician's order, dated 01/29/25, specified that all appropriate medications should be administered with food or a snack. On the day of observation, the resident reported having already eaten his meal but had not yet received his morning medications, expressing a preference to receive them with his meal to avoid stomach irritation. During interviews, an LPN stated that she considered the order to be a nursing order rather than a physician's order and believed it should have been discontinued after the resident's recent hospital stay. The LPN acknowledged discussing medication administration with the resident upon his return from the hospital and indicated she should have discontinued the order, as she believed it was no longer necessary. However, the resident continued to express a preference for receiving medications with meals, particularly in the morning, which was not being honored at the time of the survey.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review, indicating that the required protocols for protecting confidential resident information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the condition at the time of the deficiency are provided in the report.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of resident funds, resulting in unauthorized use of debit cards and significant financial losses for two residents. In one case, a resident was admitted to the hospital and subsequently passed away, after which $1,300 was withdrawn from her account. The facility was unable to determine who made the withdrawals or purchases, and all relevant information was turned over to law enforcement. The investigation could not substantiate abuse, neglect, or misappropriation, but the loss of funds remained unresolved. In another instance, a resident reported that his debit card had been stolen by a former CNA, who was related to a current staff member. The resident discovered the theft after being denied assistance due to the existence of a bank account with missing funds. Upon investigation, it was found that approximately $23,000 was missing from his account. The resident stated that he had given his food card and PIN to staff to purchase groceries, but did not recall giving his debit card, which was later found to be missing. The resident expressed feelings of betrayal and loss of trust as a result of the incident. Interviews with facility staff revealed that the missing debit card and financial discrepancies were not promptly reported or investigated. Staff members failed to follow up on the resident's concerns or assist in obtaining necessary bank statements for benefit applications. The lack of timely intervention and reporting allowed the misappropriation to go undetected for an extended period, impacting the residents involved.
Failure to Notify Provider and Emergency Contact of Resident Transfers
Penalty
Summary
The facility failed to notify the resident's provider and emergency contact (EC) of changes in condition and hospital transfers for one resident with multiple serious diagnoses, including acute respiratory failure, heart failure, kidney disease, and esophageal cancer. Record review showed that on several occasions, the resident was transferred to the hospital due to shortness of breath and low hemoglobin levels, as identified by the dialysis provider, but there was no documentation that the provider or EC was informed of these transfers. Additionally, when the resident developed moderate swelling in the left arm and was transferred to the hospital per provider's order, there was again no indication that the EC was notified. Interview with a registered nurse confirmed that the EC had not been contacted during these events, as required, and this was corroborated by the absence of documentation in the daily care notes. The deficiency was noted as a repeat from a previous survey, indicating a continued failure to communicate significant changes in the resident's condition and hospital transfers to both the provider and the EC.
Failure to Revise and Update Resident Care Plans as Required
Penalty
Summary
The facility failed to ensure that care plans were revised and updated as required for six residents. Specifically, staff did not conduct quarterly care plan meetings for five residents in accordance with their admission and Minimum Data Set (MDS) assessments. Record reviews showed that the intervals between care plan meetings exceeded the required quarterly schedule for these residents, as confirmed by the Director of Nursing. The care plan meetings were not held within the expected 90-day timeframe, resulting in lapses in the review and updating of residents' care plans. Additionally, the facility did not update the care plan for a resident with a colostomy to reflect that the resident and the resident's family were providing colostomy care. Physician orders indicated that nursing staff were responsible for changing the colostomy wafer and pouch, but interviews with the resident's family and the Assistant Director of Nursing confirmed that the family frequently performed this care. This information was not included in the resident's care plan, despite staff awareness of the family's involvement.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed that staff failed to maintain sanitary food storage and handling practices in the kitchen and dry storage areas. Specifically, three large cheese pizzas and thirteen containers of chocolate chip cookies were found in storage without labels or dates. A large cardboard box of green beans was left open to air in the kitchen freezer, and several food items, including a package of tortillas, two packages of hamburger buns, and one package of hotdog buns, were stored past their expiration dates. During an interview, the Dietary Manager confirmed these findings and acknowledged that all food items should be labeled, dated, stored appropriately, and not expired. These deficiencies were identified as affecting all 117 residents listed on the facility's census at the time of the survey.
Failure to Assess and Document Resident's Skin Issue
Penalty
Summary
A resident with a sore and redness near the right eye reported pain and uncertainty about the cause, stating he may have scratched himself due to lack of hand control. The resident indicated he had informed someone about the wound, but was unsure who, and stated that nursing staff had not examined the area as of the interview date. The Director of Nursing was unaware of any skin issue for this resident and stated that such concerns should be reported to a nurse and documented on shower sheets. The Assistant Director of Nursing later confirmed the presence of a scratch near the resident's eye, noting that if a Certified Nurse Aide observed it, it should have been documented and reported. Review of the resident's shower sheets over multiple dates revealed no documentation of the skin issue, indicating a lack of assessment, documentation, and treatment for the resident's skin condition.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
A nurse entered a resident's bathroom without announcing herself while the resident was being assisted with a shower by a CNA. The resident, who was cognitively intact with a BIMS score of 15 and required substantial to maximal assistance for bathing, reported feeling disrespected and that her privacy was violated by the nurse's unannounced entry. The incident was corroborated by the resident's roommate, who confirmed that the nurse entered without warning and that the resident was visibly upset by the event. Interviews with facility staff, including the ADON, CNA, and DON, revealed that the facility's expectation is for staff to knock, wait for permission, and announce themselves before entering a room where personal care is being provided. The resident is known to be vocal about her preferences and typically only allows certain staff to assist with her care. Despite these established protocols and the resident's clear communication of her preferences, the nurse failed to follow the expected procedure, resulting in a breach of the resident's right to privacy and dignity during personal care.
Failure to Complete Timely Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a timely assessment for a resident who experienced a significant change in condition and was hospitalized. The resident, who had multiple diagnoses including paranoid schizophrenia, psychotic disorder with delusions, chronic kidney disease, diabetes, and dysphagia, exhibited symptoms such as needing help holding his head up, reduced strength in arms and legs, and slurred speech. Following these symptoms, the nurse practitioner was contacted and the resident was transferred to the hospital for evaluation. Upon the resident's return from the hospital, record review showed that the facility completed a Minimum Data Set (MDS) Discharge Return Anticipated assessment at the time of transfer and an MDS Entry assessment upon return. However, the facility did not complete a significant change in status assessment within 14 days of the event, as required. During interviews, the DON and MDS coordinator expressed uncertainty about whether an MDS change of condition assessment was necessary in this situation.
Failure to Notify Provider and Emergency Contact After Resident Fall on Blood Thinner
Penalty
Summary
The facility failed to notify the appropriate medical provider and the resident's emergency contact after an unwitnessed fall involving a resident who was prescribed a blood thinner. Documentation showed that the resident experienced a fall in the early morning hours, but there was no evidence that the on-call provider or the resident's emergency contact was notified immediately, as required. The only progress note regarding the fall was recorded later in the day, and the emergency contact reported learning about the incident only after a family member visited the facility. The resident had a history of a previous pelvic fracture and was taking Warfarin, a blood thinner, at the time of the fall. Following the incident, the resident was monitored with post-fall observations and neurological evaluations, which did not initially indicate cognitive decline or pain. However, the resident's daughter later noticed a bruise on the resident's temple and reported increased lethargy and rib pain, which led her to call emergency services for hospital evaluation. Imaging at the hospital revealed new rib fractures, though no acute life-threatening injuries were found. Interviews with facility staff, including nurses, the nurse practitioner, the assistant director of nursing, and the director of nursing, confirmed that the provider was not notified of the fall as required, especially given the resident's use of anticoagulant medication. The medical doctor also stated he was not contacted, despite documentation suggesting otherwise. Staff acknowledged that both the provider and the emergency contact should have been notified immediately after the fall.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide care that meets professional standards by administering oxygen therapy to a resident without obtaining a physician's order. Record review showed that the resident was admitted and subsequently discharged to the hospital, and during their stay, oxygen was administered on multiple occasions at varying flow rates, as documented in the electronic health record. Despite this repeated administration, there was no corresponding physician order authorizing the use of oxygen for the resident. Interviews with the resident's emergency contact and a CNA confirmed that the resident was observed wearing oxygen while at the facility. The Director of Nursing also verified, after reviewing the resident's records, that there were no physician orders for oxygen use, even though the resident received oxygen frequently. This lack of physician authorization for oxygen therapy constitutes a failure to meet professional standards of quality care.
Failure to Honor Resident Dietary Preferences and Restrictions
Penalty
Summary
A resident with documented dietary restrictions and preferences, including an inability to eat vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms, was repeatedly served these items despite clear instructions on her meal ticket. During an interview, the resident reported that she continued to receive foods she could not eat. Observation of her lunch plate confirmed the presence of mashed potatoes, which she had not eaten. Staff interviews and record reviews corroborated that the resident's dietary preferences and restrictions were not being followed, as her meal ticket clearly indicated the foods to avoid.
Inadequate Grievance Investigation and Resolution
Penalty
Summary
The facility failed to conduct a thorough investigation and adequately resolve a grievance filed by a resident. The resident, who is legally blind, reported issues with receiving cold and unappetizing meals, finding hair in his food, and experiencing delays in receiving assistance from CNAs for brief changes. The Social Services Director (SSD) only partially investigated the grievance, focusing solely on the temperature of the resident's food. The SSD did not take the temperature of the food but assumed it was warm based on visual cues. The SSD also failed to address the other concerns raised by the resident, such as the presence of hair in the food and the lack of timely assistance from CNAs. The resident expressed dissatisfaction with the resolution of his grievance, indicating that the meals remained mostly cold and that the other issues were not investigated. The Administrator acknowledged that the grievance was not investigated appropriately for each allegation and that it should not have been documented as resolved until the resident was satisfied. This lack of comprehensive investigation and resolution could lead to a decrease in the resident's quality of life, as the facility did not adequately consider or address the resident's needs.
Failure to Conduct Timely Care Plan Meetings for Residents
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents, resulting in a deficiency. Resident #35 was admitted to the facility and had their last care plan meeting on 07/24/24, with no subsequent meetings documented. During an interview, the resident could not recall having a recent care plan meeting, and the Social Services Director (SSD) confirmed that a quarterly care plan meeting was overdue. Similarly, Resident #90 was admitted and had their last care plan meeting on 07/16/24, with no further meetings documented. The resident expressed a desire for a care plan meeting, and the SSD acknowledged that a meeting was required but had not occurred. This lack of timely care plan meetings indicates a failure to update and address the residents' care needs as required.
Failure to Communicate Critical Lab Results and Ensure Medication Availability
Penalty
Summary
The facility failed to meet professional standards for two residents by not ensuring timely communication of critical lab results and availability of prescribed medications. For one resident, who had multiple diagnoses including diabetes and chronic kidney disease, the facility did not convey critical lab results to the medical provider in a timely manner. The resident vomited dark brown emesis, prompting an immediate order for a complete blood count (CBC). Although the lab results, indicating a critical hemoglobin level, were available on the same day, the provider was not informed until the following day, delaying necessary medical intervention. In another instance, a resident did not receive their prescribed medication, Eliquis, due to its unavailability during a medication pass. The nurse responsible did not check the facility's Pyxis system for the medication or notify the provider about its unavailability. The Director of Nursing confirmed that the medication should have been available in the Pyxis and that staff should have taken steps to ensure the medication was administered as ordered.
High Medication Error Rate Due to Unavailable Medication
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 23.08% during a survey. This deficiency was identified through observations, interviews, and record reviews involving two residents. Registered Nurse (RN) #2 administered medications to Resident #118, including Amlodipine, Aspirin, and Atorvastatin, as per the physician's orders dated 12/12/24. However, during the administration to Resident #122, RN #2 failed to provide Eliquis, a medication prescribed to treat and prevent blood clots, because it was not available, despite being ordered for daily administration at 7:00 am. The Assistant Director of Nursing (ADON) #1 confirmed that medications should be administered within one hour before or after the scheduled time, and any deviation from this schedule would be considered late. The failure to administer Eliquis as ordered contributed to the high medication error rate. The report highlights the facility's inability to ensure the availability and timely administration of prescribed medications, which is crucial for maintaining the residents' health and safety.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a safe and appetizing temperature for four residents, leading to a deficiency in meal quality. Residents reported that their food was often served cold, both in their rooms and in the dining room, despite having informed the staff about the issue. Observations confirmed that food items on the steam table were not maintained at safe temperatures, with several items measured well below the required 135 degrees Fahrenheit. The steam table was identified as broken, which contributed to the inability to keep food at the appropriate temperature. Interviews with residents and staff, including a cook and a registered dietitian, confirmed the issue of cold food being served. One resident had filed a grievance about the cold food, expressing dissatisfaction with the meal temperatures. The administrator acknowledged the problem and stated that dietary staff had been instructed not to serve cold food from the steam table, but the issue persisted, indicating a failure in maintaining food safety standards and resident satisfaction.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for two residents. On December 19, 2024, at 8:14 am, a Registered Nurse (RN) did not wash his hands before, during, or after administering medications to two residents. The RN drew and poured medications into cups, administered them to the residents, and returned to the medication cart without performing hand hygiene. During an interview, the RN admitted to not washing his hands and acknowledged that he should have used the hand wash stations available in the resident rooms. On December 23, 2024, the Director of Nursing (DON) confirmed that staff are expected to wash their hands before and after administering medications to residents. This failure to follow infection control practices has the potential to spread infectious diseases between residents.
Failure to Assist Resident with Personal Purchases
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not assisting with purchases that reflected the resident's interests. The resident, who was admitted to the facility on an unspecified date, expressed a preference for activities such as watching TV, painting, reading, and using a computer. The care plan, dated January 23, 2024, indicated that staff should ensure the resident had materials for these activities, including painting supplies. However, during an interview on December 17, 2024, the resident reported being unable to purchase painting materials and winter clothes, as the previous Social Services Director (SSD) who assisted with these purchases had left the facility. The resident confirmed asking facility staff for help multiple times without receiving assistance, and noted the absence of family support. The facility administrator acknowledged that the resident should have been assisted with online purchases but was not, following the departure of the previous SSD.
Failure to Provide Vegan Diet for Resident
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, specifically a vegan diet, leading to a deficiency in providing appropriate meals. The resident, identified as R #225, was admitted with a regular diet order, but had informed the admitting nurse and several CNAs of her vegan dietary preference. Despite this, she continued to receive meals that did not align with her vegan diet, such as country fried steak and eggs with bacon. The resident resorted to having family and friends bring her vegan food, as the facility did not provide meals that met her dietary needs. The deficiency was further compounded by the absence of the Kitchen Manager, who was responsible for interviewing residents about their dietary preferences. The Registered Dietitian confirmed that no interview was conducted for R #225, and the staff continued to deliver meals based on the initial regular diet order. The lack of communication and follow-up on the resident's dietary needs resulted in her not receiving the appropriate vegan meals, as evidenced by the uneaten portions of her meal trays.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by a physician for a resident during random dining observations. The resident was prescribed a regular pureed diet, which is a texture-modified diet requiring no chewing, as indicated in the Dietary Census List and the resident's care plan. However, during a lunch observation, the resident was served pureed mashed potatoes, pureed carrots, and mechanical soft meatloaf, which requires some chewing. This was contrary to the resident's dietary meal ticket, which specified a therapeutic diet. A dietary staff member confirmed that the resident should have been served pureed meatloaf instead of mechanical soft meatloaf, indicating a failure to adhere to the prescribed diet.
Failure to Provide ADL Assistance to Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident, specifically in the areas of toileting and brief changes. This deficiency was identified when the resident's daughter, who is the Power of Attorney, reviewed footage from an in-room camera she had installed to monitor her mother's care. The video from 05/28/24 showed that no staff entered the resident's room throughout the day to provide care or check on her brief, despite the resident's inability to manage these tasks independently. Upon being informed of the situation, the facility's administration conducted an investigation. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the Certified Nurses Aide (CNA) assigned to the resident did not provide care on the specified day. The CNA admitted to not checking on the resident during her 12-hour shift, as the resident did not use her call light. The facility's Administrator took immediate action by relieving the CNA of her duties and ensuring she did not return to the facility.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure wounds for a resident, identified as R #128. Upon admission, the staff did not identify existing pressure ulcers, and subsequent weekly skin checks lacked proper staging and measurement of the wounds. The resident's pressure ulcers, initially noted on the sacrum and heels, were not adequately monitored, leading to a significant deterioration in the condition of the wounds. The facility's records revealed inconsistencies and omissions in documenting the resident's wound care and progress. Despite the presence of a community-acquired pressure ulcer, the staff failed to update treatment orders or notify the physician of the worsening condition in a timely manner. The resident's care plan indicated a risk for further skin injuries, yet the staff did not report signs of skin breakdown as required. The resident's pressure ulcer eventually progressed to a stage 4, with measurements indicating a decline, but this was not communicated effectively to the physician assistant (PA) or documented in the medical records. Interviews with facility staff, including the LPN, PA, ADON, and DON, highlighted a lack of communication and documentation regarding the resident's deteriorating condition. The PA was not informed of the worsening pressure ulcer until it had significantly declined, and the ADON could not provide evidence of notifying the PA earlier. The resident's condition ultimately required hospitalization, where they were diagnosed with a sacrococcygeal decubitus ulcer and osteomyelitis, leading to hospice care. The failure to timely identify, monitor, and communicate the resident's pressure ulcer condition contributed to the deficiency noted in the report.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, leading to potential contamination and foodborne illness risks. Observations revealed that the ice machines in various locations contained black and white substances with slime, indicating improper maintenance and cleaning. The dietary staff and maintenance staff were responsible for maintaining these machines, but there was a lack of awareness and communication regarding the contamination. Additionally, staff failed to perform proper hand hygiene and glove changes, leading to cross-contamination during food preparation. Dietary aides were observed handling food and kitchen items without washing hands or changing gloves between tasks, despite being trained on proper procedures. The facility also failed to protect clean dishes and plastic ware from contamination. Observations showed that plastic ware and lids were left uncovered, exposing them to potential contaminants as staff moved around the kitchen. Clean dishes were stored improperly, with some being wet-stacked, which could lead to bacterial growth. Furthermore, pureed food was not served at the appropriate temperatures, and staff did not remove improperly heated food from service, posing a risk of foodborne pathogens. Additional deficiencies included improper storage of staff food with resident food, inadequate use of hair restraints, and failure to label and date open food items. The kitchen environment was not maintained in a clean and sanitary manner, with visible dirt, spills, and debris in various areas. The facility's failure to follow proper sanitization procedures for dishes and food preparation sinks further contributed to the risk of contamination. These deficiencies had the potential to affect all residents consuming food from the facility's kitchens.
Failure to Update and Communicate Care Plan Changes
Penalty
Summary
The facility failed to update and revise care plans for three residents, leading to deficiencies in addressing their care needs. Resident #45's care plan did not document the required assistance for Activities of Daily Living (ADL), despite the Minimum Data Set (MDS) indicating a need for partial to moderate assistance. The Director of Nursing (DON) acknowledged that the care plan should have included these requirements. Similarly, Resident #60's care plan lacked documentation of ADL requirements and activity preferences, even though the MDS showed a need for substantial and maximal assistance. Both the Activities Director and the DON confirmed these omissions. For Resident #320, the facility failed to inform the Power of Attorney (POA) about changes in the care plan, specifically regarding new behavioral symptoms. The care plan initially included behavioral symptoms, but the POA was not notified of any updates or escalations in behavior, as confirmed by both the POA and the DON. This lack of communication and documentation could result in the residents' care needs not being adequately addressed.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in offering and providing baths and showers as per their care plans. Resident #45, who required partial/moderate assistance, was supposed to receive a bath or shower twice a week, but records showed inconsistencies in meeting this schedule. Observations and interviews revealed that the resident often received only one shower a week due to staff shortages, which left the resident feeling unclean. Staff, including a CNA and LPN, confirmed that the resident did not frequently refuse showers and acknowledged the failure to meet the scheduled bathing routine. Similarly, Resident #60, who required substantial/maximal assistance, was also not provided with the scheduled two baths or showers per week. Despite changes in the bathing schedule, records indicated that the resident did not consistently receive the required number of baths or showers. Interviews with the resident and staff confirmed that the resident was not refusing showers and that the staff was aware of the deficiency in providing the necessary care. The DON acknowledged that both residents were not given the appropriate number of baths or showers as per their schedules.
Medication Mismanagement: Pills Left Unattended on Bedside Table
Penalty
Summary
The facility failed to ensure that medications were not left unattended on a resident's bedside table, which posed a potential risk to the health of all residents on the 400 hall. During an observation, a total of 12 pills were found on a resident's bedside table, including Ranolazine, Mucus Relief DM, and Pantoprazole Sodium. The resident was unaware of the presence of these medications or how long they had been there. A review of the resident's physician orders and medication administration records confirmed that these medications were prescribed and administered regularly. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and a Certified Medication Aide, revealed that the medications were left on the bedside table by a Certified Medication Aide. The staff acknowledged that medications should not be left unattended and that they are required to observe residents taking their medications during administration. This oversight in medication management could lead to residents taking incorrect medications or dosages, although the report does not specify any actual harm that occurred.
Failure to Follow Nutritionally Calculated Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that staff followed nutritionally calculated recipes for pureed diets, which were approved by the Registered Dietician (RD). This deficiency was observed during meal preparation, where staff did not measure ingredients accurately or follow the provided recipes. For instance, a staff member added an unmeasured amount of chicken-flavored powder to pre-measured vegetables and did not have a recipe for the pureed vegetables. Similarly, another staff member guessed the amount of gravy added to pureed chicken, deviating from the recipe that specified precise measurements. The Dietary Manager (DM) admitted to not following the recipe for Texas toast due to time constraints and a lack of awareness of the recipe's existence. The DM was responsible for overseeing the kitchen operations, including the preparation of pureed foods, and was expected to ensure staff followed the recipes. The RD confirmed that menus and recipes are reviewed every six months and expected dietary staff to adhere to them. The failure to follow these recipes had the potential to affect the nutritional requirements of all six residents who consumed pureed meals.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices for four residents, as observed during a survey. For two residents, nasal cannulas used for oxygen delivery were not labeled with the date of change, contrary to the physician's orders and facility protocol, which required changing and labeling every shift. Observations revealed that the oxygen tubing was left on the floor, and staff interviews confirmed the absence of date labels, indicating a lapse in following the established procedures for infection control. Additionally, the facility did not store CPAP equipment and nebulizers appropriately for two other residents. The CPAP masks and nebulizers were found unsealed and placed on nightstands with other personal items, rather than being stored in clean bags as required. Staff interviews, including those with CNAs, LPNs, and the Director of Nursing, confirmed the improper storage and acknowledged the failure to comply with the facility's infection control policies. These deficiencies could potentially lead to the spread of infections among residents.
Failure to Provide Required Eating Assistance Device
Penalty
Summary
The facility failed to provide necessary assistance devices for a resident, identified as R #13, who required a sippy cup for meals. This deficiency was identified through observation, record review, and interview. The resident's Annual Nutritional Assessment, completed by a Registered Dietitian, recommended the use of a sippy cup, and there was a physician's order dated 04/01/24 for a sippy cup to be provided with all meals. Additionally, the resident's meal ticket for 07/18/24 included a note for a sippy cup. However, during a lunch observation on 07/18/24, the resident was served a meal without the sippy cup. An interview with an LPN confirmed that the sippy cup was not provided, as the LPN stated she had never seen one with the resident's meal.
Failure to Honor Resident's Rights in Medication Administration
Penalty
Summary
The facility failed to ensure the rights of a resident when it administered medication to reduce the resident's sexual feelings and desires without proper consent. The resident, who had vascular dementia, psychotic disturbance, mood disturbance, and cognitive communication deficit, was observed engaging in consensual sexual activity with another resident. Despite the psychologist's assessment that the resident had the capacity to consent to sexual activity, the Nurse Practitioner and Medical Director decided to increase the resident's escitalopram dosage to dampen his libido, citing concerns about his decisional capacity and inability to recall the incident. The resident's daily care notes documented an incident where the resident was found engaging in sexual activity with another male resident in the open doorway of a room. The CNA who observed the incident reported that the engagement appeared consensual and assisted the resident in pulling up his pants. The psychologist noted that residents of long-term care have the right to sexual expression and did not recommend libido dampening medication. However, the Nurse Practitioner and Medical Director disagreed, leading to an increase in the resident's medication dosage. Interviews with facility staff, including the CNA, NP, psychologist, and Medical Director, revealed differing opinions on the resident's capacity to consent to sexual activity. The Medical Director ultimately decided to implement the NP's recommendation to increase the resident's escitalopram dosage, despite the psychologist's assessment. This decision was based on the belief that the medication would help manage the resident's sexual drive, but it failed to honor the resident's right to self-determination and communication.
Excessive Dose of Anti-Depressant Administered Without Adequate Indications
Penalty
Summary
The facility administered an anti-depressant medication, escitalopram, to a resident at an excessive dose without adequate indications for its use. The resident, who has multiple diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and cognitive communication deficit, was initially prescribed 5 mg of escitalopram daily. Following an incident where the resident was found engaging in sexual activity with another male resident, the Nurse Practitioner recommended increasing the dose to 10 mg to dampen the resident's libido, despite no increase in the resident's level of depression being documented. The Medical Director reviewed and accepted the Nurse Practitioner's recommendation to increase the escitalopram dosage, citing that anti-depressants can reduce sexual drive. However, the Medical Director acknowledged that the prescribed anti-depressant was for depression and not for managing sexual behavior. The resident did not have a past history of sexual acting out, and both the Medical Director and the Nurse Practitioner stated that the resident was unable to make informed decisions about sexual interactions or other care needs, yet the resident was his own decision maker without a guardian. The Director of Nursing confirmed that the resident was pleasant and interactive, with no recent changes in behavior indicating a change in mental status or increased depression. The deficiency lies in the facility's decision to increase the resident's anti-depressant dosage without adequate indications for its use, potentially leading to overmedication and associated 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.
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