Spring River Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roswell, New Mexico.
- Location
- 3200 Mission Arch Drive, Roswell, New Mexico 88201
- CMS Provider Number
- 325044
- Inspections on file
- 23
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Spring River Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with paraplegia, cellulitis, and diabetes was discharged without confirmation that home health services were arranged, despite physician orders and a care plan indicating the need for such services. Facility staff could not verify that the referral to the home health agency was sent or received, and the agency had no record of receiving the referral or admitting the resident.
Two residents with significant medical needs did not have access to a functioning call light system in their rooms, as confirmed by both staff and direct observation. The facility's policy requires working call lights or alternative communication devices, but these were not provided or maintained for the affected residents.
The facility failed to maintain complete and accurate medical records for two residents. One resident's records lacked documentation of a change of condition and the reason for hospital transfer due to shortness of breath. Another resident's records did not describe events leading to a change in condition and death, despite a hospice referral. The DON confirmed the absence of necessary documentation.
A resident with a complex medical history developed a fever, and the facility failed to notify the physician as required by the resident's care plan. Despite orders to contact the physician before administering acetaminophen for fever, nursing staff gave the medication without notification. Documentation confirmed the oversight, and interviews with the DON and medical director acknowledged the failure to follow physician orders.
A resident with dementia and other health issues was administered acetaminophen for a fever without notifying the physician, contrary to medical orders. The facility's staff documented the administration and effectiveness of the medication but failed to follow the order to contact the provider when the resident developed a fever. The medical director confirmed that the staff should have adhered to the physician's instructions.
The facility did not ensure that the consultant pharmacist's recommendations from monthly drug regimen reviews were reviewed by the physician. The DON and Administrator confirmed the lack of documentation and completion of these reviews before November 2024, potentially affecting all 96 residents.
The facility failed to provide adequate support staff for food and nutrition services, leading to delayed meal services. Observations showed meals were served significantly later than scheduled, causing frustration among residents. One resident vocalized and banged on the table due to delays, while another fell asleep waiting for assistance. The Administrator acknowledged the issue of late meal service.
The facility did not have a QAPI plan in place, affecting all 96 residents. The Administrator confirmed the absence of a QAPI plan, records, and monitoring system since July 2024. Despite a policy commitment to QAPI principles, the facility failed to implement these across care and service areas.
The facility failed to implement an effective infection prevention and control program, as observed by surveyors. A Unit Secretary entered rooms with special precautions without PPE, and PPE disposal containers were incorrectly placed outside rooms. The DON confirmed the absence of necessary documentation and program implementation due to previous management lapses.
The facility did not implement a comprehensive antibiotic stewardship program, affecting all 96 residents. The DON admitted to the lack of documentation for the program, which was not in place before November 2024. The facility's policy requires an ASP with protocols and monitoring, with the IP responsible for the program and the Administrator accountable for compliance.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented care needs. One resident's MDS inaccurately stated bedrails were not in use, another's was not updated after returning to the facility, and a third's incorrectly indicated dialysis treatment. These inaccuracies were confirmed by the DON.
The facility failed to complete comprehensive care plans for three residents, affecting the implementation of preventative measures. One resident's care plan omitted prescribed medications, another's lacked focus, goals, and interventions, and a third's did not include Foley Catheter care. The DON confirmed these deficiencies.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their care needs. One resident's plan lacked interventions for pain management, another's was incomplete for anti-depressant use, a third's did not reflect a left ankle fracture, and a fourth's was not updated for Foley Catheter use. The DON confirmed these omissions, indicating care plans were not updated as required.
A facility failed to provide proper Foley catheter care for a resident with chronic urinary issues, leading to a deficiency. The resident's catheter care orders were incomplete, lacking details such as catheter and balloon size, and necessary maintenance orders were not documented. The DON confirmed the oversight, highlighting the importance of proper documentation and care for residents with chronic conditions.
A medication error occurred when an RN mixed Guaifenesin and Lamotrigine in a single cup for a resident's feeding tube, contrary to the facility's policy requiring separate administration. This resulted in a medication error rate of 6.45%, exceeding the acceptable threshold.
The facility failed to ensure that medications and medical supplies in the North Medication Storage room were not expired. Observations revealed expired laxative enemas, Ibuprofen, and needless connectors. A registered nurse confirmed that these items should have been discarded.
The facility failed to ensure that two residents had completed and signed consent or refusal forms for the pneumococcal vaccine. One resident had not been offered the vaccine since 2019, and another resident's records lacked evidence of the vaccine being offered. The facility's policy requires offering the vaccine after education but does not specify the frequency.
The facility failed to offer COVID-19 vaccinations to three residents, as their EHRs showed no evidence of offers after their last vaccinations in 2021 and 2022. This was confirmed by the DON, despite the facility's policy requiring adherence to CDC guidelines for vaccination in LTC settings.
A facility failed to ensure a resident was free from unauthorized physical restraints, specifically bed rails, which were used without orders, consent, or documentation. The resident's records indicated a preference against bed rails, and the MDS assessment did not document their use. The DON confirmed the lack of authorization for the bed rails.
A resident with multiple health conditions, including MS and anxiety disorder, was found smoking in his room despite requiring supervision. The facility's care plan stated smoking materials should be kept at the nurses' station, but the resident had access to them, leading to unsupervised smoking. The facility had previously allowed residents to hold their smoking supplies, contributing to this deficiency.
A facility failed to monitor a resident for side effects of Clopidogrel Bisulfate and Trazadone, as confirmed by the DON. The resident was prescribed these medications for daily use, but the December 2024 medication administration record showed no monitoring for side effects, leading to a deficiency in medication management.
The facility did not post the required daily nurse staffing data, including the facility name, date, and hours worked by RNs, LPNs, and CNAs, as well as the resident census. This was observed at the main entrance, and a Medical Records staff member confirmed the omission.
The facility failed to monitor and address significant weight loss in four residents, leading to a deficiency in nutritional care. One resident lost 37.3 pounds in 41 days without proper monitoring or intervention, while another resident's weight dropped from 221.8 to 181.4 pounds over several months. Despite care plan goals, residents consistently consumed less than the targeted meal percentages, and the facility did not notify the nutritionist or physician about the weight loss. Interviews with staff revealed a lack of action in response to documented meal consumption and weight loss.
The facility failed to create comprehensive care plans for two residents, neglecting to address specific medical needs such as wound care, surgical aftercare, and significant weight loss. The DON confirmed these omissions, highlighting deficiencies in the care planning process.
The facility failed to provide necessary treatment and services for pressure ulcer care for two residents, leading to deficiencies in promoting healing and preventing new ulcers. One resident's ulcer was not measured or treated for over a month, while another developed an ulcer without documentation or treatment orders. The DON confirmed these lapses in care and documentation.
A resident experienced a significant weight loss of 24.8% over four months, which was not documented in the MDS assessment. The DON confirmed the oversight, acknowledging that the weight loss should have been recorded.
The facility failed to lock treatment and medication carts while unattended, risking unauthorized access to medical supplies and personal health information for all 103 residents. Observations revealed unlocked carts in front of the memory unit and on the 100 hall. Staff, including a CNA, LPN, and CMA, confirmed the carts should have been locked, and the DON acknowledged the requirement for securing them.
The facility failed to respect residents' rights, resulting in deficiencies in dignity and self-determination. A resident with a fracture was forced into a mechanical lift despite her refusal, causing distress and pain. Another resident was left in a soiled brief during meals due to a policy misunderstanding, leading to embarrassment. Additionally, a resident was yelled at by staff when trying to visit a friend, highlighting a lack of respect for resident rights.
Two residents with urinary catheters had incomplete care plans that failed to document the presence of the catheters and provide care instructions. The Director of Nursing confirmed these omissions, which could result in staff not understanding or implementing necessary treatments.
The facility failed to meet professional standards of care for three residents due to improper handling of catheters and medications. A resident's urinary catheter was pulled out during a transfer, and two residents lacked physician orders for catheter care. Additionally, a CMA was observed handling medication unsafely, leading to incomplete dosing.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. One CNA completed no training, another completed only two hours, and a third completed four hours. The Administrator confirmed these CNAs continued to work shifts without meeting training requirements.
A resident reported that a CNA yelled at him during a transfer, mishandling his catheter bag. The facility initially treated the incident as a customer service issue and only reported it to the State Survey Agency after the Ombudsman intervened, resulting in a delay in reporting the abuse allegation.
A resident with an indwelling urinary catheter reported verbal abuse by a CNA during a transfer. The facility's investigation was incomplete, lacking interviews with other residents and was submitted late to the State Agency. The Administrator partially substantiated the complaint but failed to meet the required investigation standards.
A facility failed to complete a baseline care plan for a resident admitted for surgical aftercare following toe removal. The resident, with diabetes and an infection, needed help with transfers and showering. The EHR lacked a care plan, which the DON confirmed should have been completed within 48 hours.
A resident with multiple diagnoses, including fractures and reduced mobility, had an indwelling urinary catheter that was accidentally pulled out during a transfer. The incident was not documented in the resident's EHR, as confirmed by the DON, indicating a failure to maintain complete and accurate medical records.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were in place prior to the discharge of a resident who required ongoing care. The resident, who was admitted with paraplegia, cellulitis of the left lower limb, type 2 diabetes, and a need for assistance with personal care, had a documented goal to return to the community. The care plan and physician's note indicated that home health services were to be arranged upon discharge. However, the facility's records show that the referral to the home health agency (HHA) and the physician's orders were both dated on the day of discharge, with no confirmation that the HHA received or accepted the referral. Interviews with the facility's Social Services staff revealed that the resident initiated the discharge the day before leaving, and although the staff encouraged the resident to stay an additional day to allow time to arrange services, the resident agreed but was still discharged the following day. The Social Services staff could not provide evidence that the referral to the HHA was successfully sent or received. Additionally, the HHA representative confirmed that there were no records of the resident being admitted to their services or of receiving any orders for care.
Failure to Maintain Functioning Call Light System for Two Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents who required assistance. For the first resident, who had diagnoses including acute and chronic respiratory failure, major depressive disorder, epilepsy, generalized anxiety disorder, and required help with personal care, both the resident and a CNA observed that the call light in the resident's room did not activate the external light or provide any visible indication when pressed. This was confirmed during interviews and direct observation, with the CNA acknowledging the malfunction. For the second resident, who had Alzheimer's disease, dysphagia, and other medical conditions, a similar issue was observed. The CNA attempted to activate the call light in the resident's room, but it did not function. The CNA stated an intention to document and report the issue. The facility's policy requires that each resident have access to a working call light or alternative communication device in their room, bathroom, and bathing area, and that staff promptly report and address any malfunctions. However, these requirements were not met for the two residents reviewed.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, which could result in staff being unaware of the residents' daily care events, changes, and needs. For the first resident, the records lacked documentation of a change of condition, assessment of symptoms, or progress notes indicating the need for transfer due to shortness of breath. The resident's vital signs were last recorded without any indication of elevated temperatures or breathing issues, and there was no documentation explaining the reason for the ambulance call and subsequent hospital transfer. Interviews with staff confirmed the absence of necessary documentation and the expectation for records to be accurate and complete. For the second resident, the records did not include documentation or descriptions of events leading up to the resident's change in condition and subsequent death. The resident was referred to hospice services, but the electronic health record lacked details about the change from baseline condition. The Director of Nursing confirmed the absence of documentation and reiterated the expectation for complete and accurate records, especially when a resident experiences a change in condition.
Failure to Notify Physician of Resident's Fever
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who developed a fever. The resident, who had a complex medical history including unspecified dementia, muscle weakness, and a history of myocardial infarction, was admitted with physician orders for acetaminophen to be given as needed for pain or fever. However, a subsequent physician's recommendation specified that acetaminophen should only be given for pain, and the physician should be notified if a fever occurred. Despite this order, nursing staff administered acetaminophen to the resident on multiple occasions for a low-grade fever without notifying the physician. Documentation in the resident's electronic health record confirmed the administration of acetaminophen for fever and noted its effectiveness, but failed to record the physician's notification. Interviews with the Director of Nursing and the medical director confirmed that the physician should have been contacted when the resident developed a fever, indicating a lapse in following the physician's orders.
Failure to Follow Medical Orders and Notify Provider of Resident's Fever
Penalty
Summary
The facility failed to ensure quality care that meets professional standards for a resident when it did not follow a medical order and failed to notify the provider about changes in the resident's condition. The resident, who was admitted with multiple diagnoses including unspecified dementia, cognitive communication deficit, and muscle weakness, had a physician's order for acetaminophen to be given for pain only, with instructions to notify the physician if a fever occurred. Despite this, nursing staff administered acetaminophen for a low-grade fever without notifying the physician, as documented in the progress notes. The progress notes revealed that on multiple occasions, acetaminophen was administered to the resident for a fever, and the effectiveness was noted without documenting the new temperature or the reason for administration. The medical director confirmed that staff should have followed the physician's order and contacted the provider when the resident developed a fever. This failure to implement care orders and notify the provider about changes in the resident's vital signs could likely lead to staff and the physician being unaware of changes in the resident's condition, potentially worsening the resident's condition.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations from the monthly drug regimen reviews were reviewed and responded to by the physician. This deficiency was identified during interviews with the Director of Nursing (DON) and the Administrator. The DON admitted that there was no documentation available to show that medication regimen reviews were completed before November 2024, and although the pharmacist's printed recommendations could be provided, there was no evidence of physician review. The Administrator confirmed that the pharmacist's recommendations had not been completed prior to November 2024. This oversight has the potential to affect all 96 residents in the facility, as identified by the census provided by the Administrator.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support staff to effectively carry out the functions of the food and nutrition services, resulting in delayed meal services for residents. During an initial observation, the dining room doors were found closed and locked due to insufficient staffing. The facility's posted mealtimes were not adhered to, with meals being served significantly later than scheduled. For instance, lunch was served fifty-three minutes late, and breakfast was served forty-six minutes late. Interviews with residents revealed dissatisfaction with the delays, as one resident expressed frustration with the waiting times, and another resident adjusted her schedule due to the consistent lateness of meals. Further observations highlighted the impact of these delays on residents. During a dining observation, one resident began vocalizing and banging on the table due to the delay in meal service, while another resident fell asleep waiting for assistance with dinner. The Administrator acknowledged the issue of late meal service during an interview, indicating awareness of the problem. These findings demonstrate the facility's failure to meet the dietary needs of its residents in a timely manner due to inadequate staffing in the food and nutrition services department.
Failure to Implement and Maintain QAPI Plan
Penalty
Summary
The facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) Plan, which could potentially affect all 96 residents. During an interview, the Administrator admitted to not having a QAPI plan in place, lacking records of QAPI activities, and not having a QAPI monitoring system since July 2024. A review of the facility's policy for QAPI, dated October 2022, indicated a commitment to integrating QAPI principles across all care and service areas, including clinical care, quality of life, and patient choice. However, the absence of an active QAPI plan suggests a failure to adhere to these stated commitments.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to develop and implement an ongoing infection prevention and control program, which is crucial for preventing, recognizing, and controlling the onset and spread of infections. During observations, it was noted that signs indicating special contact and droplet precautions were present on the doorways of certain rooms. However, a Unit Secretary was observed entering these rooms without using the necessary personal protective equipment (PPE), which was available on carts outside the rooms. Additionally, containers for discarding used PPE were incorrectly placed outside the rooms, contrary to the facility's protocol that requires them to be inside the rooms for proper disposal before exiting. The Director of Nursing (DON) confirmed the absence of documentation for the infection prevention and control program, acknowledging that the program had not been developed or implemented prior to November 2024 due to the previous DON's failure to complete these duties. The facility's policy on Infection Control Outcome and Process Surveillance and Reporting outlines the responsibilities of the Infection Preventionist, including conducting regular outcome and process surveillance. However, the lack of documentation and adherence to these protocols indicates a significant lapse in infection control practices, potentially affecting all 96 residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is essential for optimizing infection treatment and minimizing adverse events from antibiotic use. This deficiency potentially affects all 96 residents in the facility. During an interview, the Director of Nursing (DON) admitted that there was no documentation available for the surveyors to review because the program had not been implemented before November 2024. The facility's policy, revised on 08/07/23, mandates the implementation of an Antibiotic Stewardship Program (ASP) with protocols and monitoring systems, with the Infection Preventionist (IP) responsible for the program and the Administrator ultimately accountable for compliance. The DON and Medical Director are tasked with executing ASP standards. The Administrator confirmed that the program was not in place prior to November 2024.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to inadequate services and support. For one resident, the MDS assessment inaccurately indicated that bedrails were not in use, despite a bed safety assessment showing they were safe to use with monitoring. Another resident's MDS assessment was not updated after their return to the facility, and it incorrectly stated that bedrails were not in use, even though the resident had expressed a preference against them. The Director of Nursing confirmed these inaccuracies during an interview. Additionally, a third resident's MDS assessment inaccurately documented that the resident was on dialysis, although there were no medical orders for dialysis, and the resident had never been on dialysis. This discrepancy was also confirmed by the Director of Nursing. These inaccuracies in the MDS assessments highlight a failure in the facility's processes to ensure that residents' assessments are current and reflective of their actual care needs and preferences.
Incomplete Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure the completion of comprehensive care plans for three residents, which could potentially affect the staff's ability to implement necessary preventative measures for the residents' health and well-being. For one resident, the care plan did not include the use of anticoagulant and psychotropic medications, despite the resident being prescribed and administered Clopidogrel Bisulfate and Trazadone. The Director of Nursing (DON) confirmed the omission of these medications from the care plan, acknowledging the requirement for their inclusion. Another resident's care plan was found to be incomplete, lacking focus, goals, and interventions, despite the resident having multiple diagnoses, including diabetes with complications, sepsis, insomnia, and depression. Additionally, a third resident's care plan failed to include Foley Catheter care, despite the resident having conditions such as a urinary tract infection and obstructive uropathy. The DON verified the incompleteness of the care plans for all three residents.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in addressing their care needs. For one resident, the care plan did not include necessary interventions for monitoring pain, non-pharmacological interventions, and the effectiveness of pain medication, despite an active order for Hydrocodone-Acetaminophen. Another resident's care plan was incomplete regarding anti-depressant medication, lacking individualized focus, goals, and interventions. Additionally, a resident with a left ankle fracture did not have their care plan revised to reflect this condition, and another resident's care plan was not updated to include the use of a Foley Catheter. Interviews with the Director of Nursing (DON) confirmed these omissions, indicating that the care plans were not updated as required for changes in conditions or on a quarterly basis. The failure to revise these care plans could result in the residents' care and needs not being adequately addressed. The report highlights the lack of timely updates and revisions to care plans, which are essential for ensuring appropriate and effective care for residents with changing medical conditions.
Deficient Foley Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate Foley catheter care for a resident, leading to a deficiency in maintaining sanitary conditions and potentially increasing the risk of urinary tract infections. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy, adult failure to thrive, and chronic urinary issues, had an indwelling catheter upon admission. However, the facility did not have complete orders for the catheter care, including the size of the catheter and balloon, and the necessary maintenance orders were not input into the computer system. During interviews, the Director of Nursing confirmed that the orders for the resident's indwelling urinary catheter were incomplete and not properly documented. The resident had a history of chronic UTIs and was a chronic catheter patient, which underscores the importance of proper catheter care. The lack of complete and accurate orders for catheter maintenance, such as changing the Foley catheter every 30 days, measuring and recording urine output, and checking for leaks, contributed to the deficiency identified by the surveyors.
Medication Administration Error via Feeding Tube
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by three medication errors occurring out of 31 opportunities, resulting in an error rate of 6.45%. This deficiency was observed during medication administration for one of the eight residents involved. Specifically, a Registered Nurse (RN) administered medications incorrectly via a feeding tube. The RN mixed Guaifenesin liquid with a crushed Lamotrigine capsule in a single cup, contrary to the facility's policy, which mandates that each medication be administered separately to avoid interaction and clumping. The incident involved a resident who was prescribed Guaifenesin syrup and Keppra solution for congestion and seizures, respectively. The RN, during an interview, indicated that she believed it was acceptable to mix medications based on their quantity. However, the facility's policy clearly states that medications should be administered separately through enteral tubes. The Director of Nursing confirmed that the expectation is for medications to be given separately, highlighting a deviation from established protocols during the administration process.
Expired Medications and Supplies Found in Storage Room
Penalty
Summary
The facility failed to ensure that all medications and medical supplies in the North Medication Storage room were not expired. During an observation, three boxes of laxative enemas and one bottle of opened Ibuprofen were found to be expired. Additionally, four needless connectors were also discovered to be expired. These findings were confirmed during an interview with a registered nurse, who acknowledged that the expired items should have been discarded.
Deficiency in Pneumococcal Vaccination Consent Process
Penalty
Summary
The facility failed to ensure that residents had completed and signed consent or refusal forms for the pneumococcal vaccine, leading to a deficiency in their immunization process. Specifically, two residents, identified as R #38 and R #74, were not offered the pneumococcal vaccination as required. For R #38, the Electronic Health Record (EHR) showed that the last pneumococcal vaccine was administered on 04/25/19, and there was no evidence of the vaccine being offered again since then, despite the Director of Nursing (DON) acknowledging that it should have been offered in April 2024. Similarly, R #74's EHR lacked evidence of the pneumococcal vaccine being offered, which was confirmed by the DON. The facility's policy, revised on 09/13/24, mandates that pneumococcal vaccinations be offered after residents receive education, but it does not specify the frequency of these offers.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to three residents, as identified in a review of their Electronic Health Records (EHRs). Resident #36's EHR showed that the last COVID-19 vaccination was received in October 2022, and there was no evidence of an offer for vaccination after that date. Similarly, Resident #38's EHR indicated the last vaccination was in November 2021, with no subsequent offer documented. Resident #74's EHR also lacked any evidence of an offer for the COVID-19 vaccination. These findings were confirmed during an interview with the Director of Nursing (DON). The facility's COVID-19 Vaccination policy, revised in February 2024, mandates offering vaccinations in line with CDC recommendations. The CDC advises that individuals in long-term care settings receive COVID-19 vaccinations, with specific guidelines for different age groups. Despite these guidelines, the facility did not adhere to its policy, as evidenced by the lack of documentation and offers for vaccination to the residents in question.
Unauthorized Use of Bed Rails as Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically bed rails, without proper authorization. This deficiency was identified for one resident, who was observed with small side rails at the head of the bed used for positioning. A review of the resident's physician orders revealed that the use of bed rails was not ordered, and the resident's consent form indicated a preference against bed rails. Additionally, the 5-day MDS assessment did not document the use of bed rails. During an interview, the Director of Nursing confirmed the absence of orders, consent, and MDS documentation for bed rail use, acknowledging that bed rails should not have been used under these circumstances.
Resident Smokes Unsupervised in Room Due to Lapse in Policy Enforcement
Penalty
Summary
The facility failed to prevent a resident from smoking in his room, which is a violation of the facility's smoking policy. The resident, who has multiple diagnoses including multiple sclerosis, anxiety disorder, and major depressive disorder, was admitted to the facility with a requirement for supervision while smoking. Despite this, the resident was found to be in possession of cigarettes and a lighter, which he kept in his bag, and admitted to smoking in his room. This was confirmed by a Certified Nursing Assistant (CNA) who stated that the resident was aware that smoking inside the building was not allowed but continued to do so. The facility's comprehensive care plan for the resident, revised in November 2024, clearly stated that the resident may smoke only with supervision and that smoking materials should be maintained at the nurses' station. However, during an interview with the Administrator, it was revealed that the facility had allowed residents to hold their smoking supplies instead of keeping them locked at the nurses' station. This lapse in policy enforcement led to the resident smoking unsupervised in his room, creating a potential hazard.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of medications for one resident, leading to a deficiency in medication management. The resident had physician orders for Clopidogrel Bisulfate, an anticoagulant, and Trazadone, a psychotropic medication, both prescribed for daily administration. However, a review of the resident's medication administration record for December 2024 showed that there was no monitoring for side effects associated with these medications. During an interview, the Director of Nursing confirmed that the facility did not monitor the resident for side effects of the anticoagulant and psychotropic medications, which constitutes a failure to address potential adverse effects and unnecessary medication use.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis at the beginning of each shift, which is a requirement. The missing information included the facility name, the current date, and the total number and actual hours worked by registered nurses, licensed practical nurses, certified nurse aides, and the resident census. This deficiency was observed on December 8, 2024, at 11:30 pm, when the nurse staffing data was not posted at the main entrance door. Additionally, during an interview at 1:35 pm on the same day, a Medical Records staff member confirmed that the nursing staff data was not posted.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in four residents, leading to a deficiency in nutritional care. Resident #1 experienced a drastic weight loss of 37.3 pounds over 41 days, which was not monitored or addressed despite recommendations from the nutritionist to obtain current weights. The resident's care plan included goals to consume more than 80% of meals and avoid significant weight changes, but these were not met, and the facility did not act on the documentation showing inadequate meal consumption. The resident was eventually hospitalized and passed away, with the family expressing concerns about the facility's care. Resident #2 also experienced significant weight loss, dropping from 221.8 pounds to 181.4 pounds over several months. Despite a care plan goal to consume more than 85% of meals, the resident consistently ate less than 25% of meals, and the facility failed to notify the nutritionist or physician about the weight loss. Similarly, Resident #3 lost 22.9% of their body weight over six months, with documentation showing they ate no more than 50% of meals. The facility did not verify the accuracy of the initial weight or address the weight loss in the care plan. Resident #4 lost 20 pounds in 38 days, equating to an 11.75% weight loss, yet their care plan did not include any goals or interventions related to this significant weight loss. The facility did not have medical orders to address the weight loss, and the Director of Clinical Operations confirmed that the weight loss was not planned. Interviews with facility staff, including the Director of Nursing, revealed a lack of action in response to the documented meal consumption and weight loss, contributing to the deficiency in nutritional care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident #1 was admitted with multiple diagnoses, including sepsis, muscle weakness, colostomy status, and surgical aftercare needs. Despite these conditions, the care plan for Resident #1 was not comprehensive, as it did not include necessary interventions for wound care, the abdominal surgical wound, foley catheter, or colostomy. The Director of Nursing confirmed that the care plan was not developed within the required timeframe and did not meet the facility's expectations for comprehensive care planning. Resident #4 was admitted with diagnoses including cerebral infarction, cellulitis, hyperlipidemia, and a laceration of the esophagus. Over a three-month period, Resident #4 experienced a significant weight loss of 11.43%, which was not addressed in the care plan. The Director of Nursing acknowledged that this significant weight loss should have been included in the care plan, indicating a failure to address the resident's nutritional needs adequately.
Deficiency in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcer care for two residents, leading to deficiencies in promoting healing and preventing new ulcers. Resident #1 was admitted with a pressure ulcer on the coccyx and a surgical wound, but the facility did not measure the ulcer or obtain timely wound care treatment orders for 34 days. The care plan intervention to provide wound treatment was also delayed by 35 days. The Director of Nursing (DON) confirmed that the orders and interventions were not implemented timely, and the wound's progress could not be assessed due to the lack of measurements. Resident #4 was admitted with intact skin but later developed a pressure ulcer, which was not documented in the baseline care plan. The facility failed to measure the ulcer or obtain medical orders for its care and treatment. The DON confirmed the absence of documentation regarding the ulcer's development and current status, as well as the lack of medical orders for its treatment. This lack of documentation and timely intervention contributed to the deficiency in pressure ulcer care for both residents.
Inaccurate MDS Assessment Due to Undocumented Weight Loss
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, which is a federally mandated assessment instrument. The resident in question was admitted with multiple diagnoses, including anemia, a thyroid nodule, type 2 diabetes with hyperglycemia, and an inflammatory disease of the prostate. A review of the resident's weight summary showed a significant weight loss of 24.8% over four months, from 207.8 pounds to 156.2 pounds. However, the MDS assessment did not document this significant weight loss. During an interview, the Director of Nursing confirmed the weight loss and acknowledged that it should have been captured in the MDS assessment, but it was not.
Unattended and Unlocked Treatment Carts
Penalty
Summary
The facility failed to ensure that all treatment and medication carts were locked while unattended, which had the potential to affect all 103 residents by allowing unauthorized access to medical supplies and personal health information. On multiple occasions, surveyors observed treatment carts located in front of the memory unit by the nurses' station and on the 100 hall being left unlocked and unattended. Certified Nursing Assistant (CNA) #5, Licensed Practical Nurse (LPN) #1, and Certified Medical Assistant (CMA) #3 confirmed that the carts should have been locked when not in use. The Director of Nursing (DON) also acknowledged that treatment carts should be secured while not in use.
Deficiencies in Resident Dignity and Rights
Penalty
Summary
The facility failed to honor the rights of residents to refuse care, resulting in a deficiency in resident dignity and self-determination. A resident with a humerus fracture was subjected to a mechanical lift for weighing purposes despite her explicit refusal and expression of pain. The resident, who was cognitively intact and preferred to manage her pain with Tylenol instead of prescription medication, was not informed of the procedure beforehand and was distressed by the experience. The facility's investigation confirmed the grievance, and the involved nurse's employment was terminated. Another resident experienced a lack of timely incontinence care, which compromised his dignity and comfort. The resident, who had multiple diagnoses including fractures and reduced mobility, was left in a soiled brief during meal times due to a misunderstanding of the facility's policy on cross-contamination. The resident expressed embarrassment and discomfort, and the Director of Nursing confirmed that the staff member involved misunderstood the policy and has since been retrained. Additionally, a resident was denied the right to visit other residents and was spoken to in an undignified manner. The resident, who was cognitively intact and actively engaged in various activities, was yelled at by a staff member when attempting to visit a friend in another unit. The incident was not reported by a witness due to fear of retaliation, and the Director of Nursing was unaware of such behavior occurring. These incidents collectively highlight a failure to respect and uphold the residents' rights to dignity and self-determination.
Deficient Care Planning for Residents with Urinary Catheters
Penalty
Summary
The facility failed to ensure that care plans were accurate and complete for two residents who had urinary catheters. For the first resident, the electronic health record indicated an admission date, and hospital discharge documentation revealed the placement of an indwelling urinary catheter. However, the care plan, last updated before the hospital visit, did not document the presence of the catheter or provide instructions for its care. This oversight was confirmed by the Director of Nursing during an interview, who acknowledged the absence of necessary documentation in the care plan. Similarly, the second resident's care plan also lacked documentation of a Foley catheter and instructions for its care, despite observations confirming the presence of the catheter. The Director of Nursing confirmed that the care plan did not reflect the resident's current medical needs, as it failed to include the catheter and care instructions. This deficiency in care planning could lead to staff not understanding or implementing the necessary treatments for the residents.
Deficiencies in Catheter Management and Medication Handling
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents, primarily due to improper handling of medical devices and medications. One resident experienced an incident where their indwelling urinary catheter was pulled out during a transfer from bed to wheelchair because the staff member forgot to unhook the catheter bag from the bed rail. This incident was not documented in the resident's Electronic Health Record (EHR), and the Director of Nursing (DON) confirmed the lack of documentation and could not identify the responsible Certified Nursing Assistant (CNA). Additionally, the facility did not obtain physician orders for the use and care of urinary catheters for two residents. Both residents had catheters placed during hospital visits, but their records lacked specific orders regarding catheter size, care, and maintenance. The care plans for these residents also did not document the presence of the catheters or provide instructions for their care. The DON acknowledged the absence of these orders and stated that it was expected for the nurse on duty to review hospital discharge documentation and contact the medical provider for necessary orders. Furthermore, a Certified Medical Assistant (CMA) was observed handling medications unsafely. The CMA prepared a Depakote Sprinkles medication capsule without wearing gloves and used her hand to sweep the medication powder off the cart and onto the floor, resulting in the resident not receiving the full dose. The DON confirmed that staff should wear gloves when handling medications, and the FDA guidelines state that if the contents of a capsule are spilled, a new capsule should be used.
Deficient CNA Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year. This deficiency was identified for three CNAs who were reviewed for compliance with the training requirements. CNA #1, hired on May 19, 2023, did not complete any training from the date of hire until September 5, 2024. The Administrator confirmed that CNA #1 continued to work shifts without completing any of the required training hours. CNA #2, hired on April 27, 2023, completed only two out of the required 12 hours of annual training by September 5, 2024. Similarly, CNA #3, hired on September 12, 2022, completed only four out of the required 12 hours of training from September 5, 2023, to September 5, 2024. The Administrator acknowledged that both CNAs continued to work shifts despite not meeting the training requirements. The Administrator stated an expectation for all CNAs to complete at least 12 hours of training per year.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Survey Agency. The incident involved a resident who reported that a Certified Nurse Assistant (CNA) yelled at him during a transfer from his bed to his wheelchair. The resident expressed concern that the CNA mishandled his catheter bag, potentially causing urine to re-enter his body, and reported the incident to the facility's Administrator on the day it occurred. However, the facility initially treated the incident as a customer service issue rather than a reportable abuse allegation. The facility's records indicate that the incident was reported to the State Survey Agency only after the Ombudsman brought it to their attention two days later. The Administrator confirmed that the report was submitted on that later date, acknowledging the delay. This failure to promptly report the allegation of verbal abuse as required by regulations put residents at risk of further abuse, as timely reporting is crucial for the protection and safety of residents.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation and document the findings regarding an allegation of abuse involving a resident. The resident, who had an indwelling urinary catheter, reported that a Certified Nurse Assistant (CNA) yelled at him during a transfer from his bed to his wheelchair. The resident expressed concern that the CNA mishandled the catheter bag, potentially causing urine to re-enter his body. The incident was reported to the facility's Administrator, who filed an Initial Incident Report with the State Agency. However, the follow-up Complaint Narrative Investigation Report was submitted late, and the investigation was deemed incomplete as it lacked documentation of observations or interviews with other residents to determine if similar incidents occurred. The Administrator admitted to partially substantiating the complaint based on the CNA's acknowledgment of a verbal argument but failed to interview other residents as part of the investigation. The follow-up report was submitted after the extended deadline, and the incident was labeled as unsubstantiated despite the CNA's admission. The Administrator acknowledged the expectation for thorough investigations to be completed and documented within the required timeframes, which was not met in this case.
Failure to Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed for a resident who was admitted for surgical aftercare following the removal of the small fifth toe on the left foot. The resident, who also has diabetes, high cholesterol, and an infection at the surgical site, reported needing assistance with transferring due to difficulty standing on the operated foot and required help with showering to prevent the wound from getting wet. Upon review, the resident's Electronic Health Record (EHR) did not contain a baseline care plan. The Director of Nursing confirmed the absence of the care plan and stated that it was expected to be completed within 48 hours of admission.
Incomplete Medical Records for Resident with Urinary Catheter Incident
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident, identified as R #3. The resident was admitted with multiple diagnoses, including fractures, pain, muscle weakness, and reduced mobility. According to the hospital discharge documentation, the resident had an indwelling urinary catheter placed. However, during an observation and interview, the resident reported that the catheter was accidentally pulled out during a transfer from bed to wheelchair because a staff member forgot to unhook the catheter bag from the bed rail. A review of the resident's Electronic Health Record (EHR) revealed that there was no incident note, nurse assessment, or explanation regarding the incident where the catheter was pulled out. The Director of Nursing confirmed that a nurse had replaced the catheter after the incident, but no documentation was found in the EHR. This lack of documentation represents a failure to maintain complete and accurate medical records, which could result in staff being unaware of the resident's care events and needs.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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