Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Anthony Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents were administered medications such as Ativan, Trazadone, Hydroxyzine, and Lorazepam for agitation, anxiety, and insomnia without corresponding diagnoses documented in their EHRs. The DON confirmed these medications were given for the indicated uses, but the lack of documented indications led to a deficiency in ensuring drug regimens were free from unnecessary drugs.
Unsecured medication carts and improper medication storage were observed. A medication cart near the nurse's station and a cart in the main hallway were found unlocked and unattended, and an LPN confirmed the carts were left unlocked. Surveyors also found expired meds and supplies in storage, including Nitroglycerin, Influenza vaccines, Uro-secure devices, IV secondary sets, Magnesium oxide, and Hemorrhoidal cream, plus Acidophilus that required refrigeration after opening but was stored on a shelf instead.
Menu items were not followed and residents were not given advance choice of meals. A resident’s meal ticket and the posted lunch menus did not match the food actually served, and the DM confirmed the menu is not always followed, stating staff do their best to make comparable food items.
Unsanitary kitchen conditions and improper food storage: The ice machine had dried residue and food particles, the coffee, juice, and tea machines were visibly dirty with dried spills, and the kitchen floor, walls, backsplash, and countertops were visibly soiled with trash, food particles, and spills. An out-of-service walk-in refrigerator still contained molded biscuits, packaged whipped butter spread, corn tortillas, hot dog buns, water, and half-used sweet and sour sauce, and the DM confirmed the equipment and food storage issues.
Infection control deficiencies were identified when EBP signs were not visible outside rooms with precautions because they were tucked behind PPE gowns, and staff did not sanitize or wash hands during lunch service after touching residents, dirty surfaces, and a dirty dish area before serving meals. An RN confirmed that staff should perform hand hygiene after such contact.
The facility failed to maintain COVID-19 vaccination documentation for 4 of 4 CNAs reviewed. Each personnel file lacked immunization history, evidence of vaccine education, and documentation that the staff member was offered the vaccine or given the opportunity to accept or decline it.
Kitchen Equipment Not Kept in Safe Operating Condition: A surveyor observed the cleaning solution dispenser above the three-compartment sink leaking water into the sink, a walk-in refrigerator posted out of service but still used to store food items including molded biscuits, and a freezer with a bottom vent that fell off and exposed wires and mechanical parts. The DM confirmed the dispenser was not supposed to leak, the walk-in refrigerator was not working, and the molded biscuits needed to be disposed of.
The facility failed to timely submit required follow-up reports to the State Survey Agency for two residents after abuse or neglect allegations. Although extensions were granted, the reports were still submitted after the due dates. The ADM, who served as the Incident Coordinator, confirmed the reports were not submitted on time.
A resident with dementia, a BIMS score of 12, and no documented wandering or elopement history was observed wearing a wander guard even though the MDS and elopement evaluation indicated he was not at risk for wandering. The resident said he was unsure why he had the device, and the ADM, an LPN, and a CRC each stated he did not exhibit wandering behaviors and should not have had a wander guard in place.
A resident with bipolar disorder, schizoaffective disorder, HTN, and a history of pulmonary embolism had a wander guard in use due to increased elopement behaviors, but the care plan did not include the elopement risk or the wander guard. An LPN confirmed the omission.
Failure to Post Daily Nurse Staffing Data: The facility did not post the nurse staffing data sheet daily at the beginning of the shift. An observation at the main entrance showed the sheet was dated two days earlier, and the Administrator confirmed the staffing information should be posted daily but was not. The required posting included the facility name, current date, RN, LPN, and CNA staffing hours, and resident census.
A resident with PVD and HF did not receive an ordered Lidocaine patch or bilateral ACE wraps as documented. Although the MAR was signed by an LPN indicating both treatments were completed, observation and interview confirmed the patch was not applied and the legs were not wrapped, and the UM verified the documentation was inaccurate.
Several residents reported filing grievances about food and showers but did not receive any outcomes or responses. The facility's policy requires documentation and response to grievances, but the Administrator could not provide evidence of investigations or communication of outcomes due to missing records.
Surveyors found that a medication cart and a treatment cart were left unlocked and unattended in the facility. Interviews with two LPNs confirmed the carts were not secured, and the DON stated that all medication carts should be locked when unattended. This failure affected all residents in the facility.
The facility did not provide meals that were palatable, attractive, or served at safe and appetizing temperatures. Two residents reported that food was often cold and did not match the posted menu, with one resident documenting multiple discrepancies between meal tickets and actual food served. Direct observation confirmed that hot foods were served below appropriate temperatures, and staff acknowledged these temperatures were not suitable for serving.
Surveyors observed peeling and chipped paint, unrepaired wall sections, and worn handrails in one hall, along with frequent use of an overhead paging system to call staff and maintenance. The Administrator confirmed these issues, which resulted in a failure to provide a comfortable, homelike environment for residents.
The facility did not have evidence of investigations into allegations of abuse, neglect, exploitation, or mistreatment for a period of several months after the previous Social Services Director left and took the Reportable Binder containing all related documentation. This resulted in a lack of records to show that such allegations were thoroughly investigated for all residents during that time.
Two residents had discrepancies between their care plans and their most current medical orders, including conflicting code statuses and outdated care preferences. The DON confirmed that care plans were not revised after changes in hospital status or resident preferences, resulting in inaccurate documentation of resuscitation status and bathing routines.
A resident who was dependent on staff for ADL support did not receive proper bathing or showering assistance, as records showed only intermittent bed baths were provided over several months. The DON confirmed that bathing services were not adequately delivered.
Staff did not implement or document required fall prevention and post-fall interventions for two residents with severe cognitive impairment and a history of falls. Despite known risks and requests from a guardian, interventions such as keeping the bed in a low position and using a fall mat were not in place, and neurochecks were not performed after falls. Documentation regarding the cause and circumstances of falls was also incomplete, as confirmed by the DON.
Three residents with significant respiratory and chronic health conditions were found using oxygen concentrators without proper labeling to indicate when the tubing was last changed, and in one case, a concentrator was assigned to the wrong individual. Medical orders required weekly tubing changes and labeling, but staff did not consistently follow these protocols, as confirmed by the DON.
A resident's advance directive and MOST form indicated Full Code status, while the physician's orders in the EHR listed Do Not Resuscitate (DNR). The DON confirmed the resident should be Full Code, revealing the resident's medical chart was not updated to reflect the correct code status.
A resident admitted after hip surgery did not receive prescribed pain medications, leading to severe pain and a call to 911. Despite having orders for Gabapentin, Norco, and Ibuprofen, the facility did not administer any medications, offering only Tylenol, which was not ordered. The resident discharged against medical advice due to inadequate pain management.
The facility failed to provide meals that were attractive, palatable, and at a safe temperature, as reported by several residents. Observations showed overcooked and dry chicken, overly soft vegetables, and grievances about soggy sandwiches and undercooked desserts. A staff member confirmed ongoing complaints about food quality.
A resident admitted with multiple diagnoses, including a Stage 3 pressure ulcer, did not have their care plan updated with necessary wound care interventions until 25 days after admission. The DON confirmed that the care plan was not comprehensive, as it lacked interventions for pressure ulcers, which should have been included within seven days of the comprehensive assessment.
A resident was discharged without a comprehensive summary, leading to confusion at the receiving facility. The discharge plan lacked updated medication orders and care recommendations, and the MAR was outdated. The receiving facility struggled to clarify the resident's care needs due to unreturned calls from the discharging facility.
The facility failed to maintain safe water temperatures in the dementia care unit, with temperatures reaching up to 125°F, posing a risk of burns to residents with cognitive impairments. Additionally, the facility did not provide adequate supervision to prevent falls for a resident with severe cognitive impairment, resulting in multiple falls and injuries without proper assessment or intervention. These deficiencies highlight significant lapses in ensuring a safe environment for residents.
The facility failed to maintain proper food storage temperatures, with the walk-in refrigerator at 49°F, above the recommended range. Perishable items were improperly stored, and the Dietary Manager acknowledged the issue. Additionally, improper hand hygiene practices were observed, with Cook1 using a sanitizer not intended for hand use. Unsanitary conditions and expired food items were found in the kitchen and dementia care unit, violating facility policies.
The facility failed to maintain the walk-in refrigerator at a safe temperature, risking food-borne illness for all 59 residents. The refrigerator was observed at 49°F, above the safe limit, with various perishable foods stored inside. Despite a high-priority work order submitted months ago, the issue remained unresolved due to vendor difficulties, as confirmed by the Maintenance Director.
The facility failed to provide restorative services as ordered for five residents, leading to potential decline in their functional abilities. Residents with various diagnoses, including quadriplegia, schizophrenia, and muscle weakness, did not receive the prescribed range of motion exercises and other restorative interventions consistently. Staffing issues, particularly with a CNA responsible for multiple duties, contributed to the lack of services. The facility's policy emphasized maintaining residents' functional abilities, but gaps in care were evident.
The facility failed to provide an ongoing program of activities for residents on the dementia care unit, affecting several severely cognitively impaired individuals. Observations showed residents wandering without engagement, and staff confirmed the absence of an Activity Aide. The deficiency was due to staffing issues, with no activities conducted since January 2024, except briefly in June.
The facility failed to maintain an environment free of flies, affecting all residents. Flies were observed in resident rooms, dining areas, and therapy rooms, landing on residents and their food. Residents, including those with dementia and physical limitations, expressed dissatisfaction with the persistent fly problem. The issue was partly due to a broken fly curtain at the smoking area door, which had been unrepaired for ten months. The facility had a pest control contract, but the use of pest spray inside was not possible.
The facility did not ensure two cognitively intact residents participated in their care planning. Despite policy requirements, there was no documentation of invitations or attendance for care plan meetings, as confirmed by the Social Service Director.
The facility failed to prevent cross-contamination during medication administration and wound care. An LPN did not perform hand hygiene between resident contacts while administering medications, contrary to facility policy. Additionally, another LPN did not change gloves or perform hand hygiene during wound care for a resident with pressure ulcers, increasing the risk of infection. These actions were confirmed by the staff involved.
The facility did not post the actual hours worked by nursing staff, affecting all residents and visitors. Observations revealed no staffing information was displayed, and interviews with the Administrator and DON confirmed the sheets were inaccessible due to issues with the posting area. Staffing sheets were kept in a box and a drawer, contrary to policy requirements.
Failure to Document Indications for Psychotropic and Sedative Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs by not providing adequate indications of use for certain medications based on the residents' diagnoses. For three residents reviewed, physician orders included medications such as Ativan, Trazadone, Hydroxyzine, and Lorazepam prescribed for conditions like agitation, anxiety, and insomnia. However, record reviews revealed that the corresponding diagnoses for agitation and insomnia were not documented in the residents' electronic health records (EHRs). For example, one resident was prescribed Ativan for agitated behavior and Trazadone for insomnia, but neither agitation nor insomnia was listed as a diagnosis in the EHR. Another resident was prescribed Lorazepam for agitation/anxiety, but anxiety was not documented as a diagnosis. Similarly, a third resident was prescribed Trazadone for insomnia without insomnia being listed as a diagnosis in the EHR. During an interview, the Director of Nursing confirmed that these medications were being administered for the indicated uses as per the physician's orders, despite the lack of corresponding diagnoses in the residents' records. The absence of documented indications for these medications constitutes a failure to ensure that drug regimens are free from unnecessary drugs, as required by regulation.
Unsecured medication carts and expired or improperly stored medications
Penalty
Summary
Safe medication storage practices were not maintained because medication carts were observed unlocked and unattended on multiple occasions. On 08/10/25, a medication cart near the nurse's station was found unlocked and unattended, and RN #1 confirmed it should have been locked. On 08/11/25, a medication cart in the main hallway was observed unlocked and unattended twice, and LPN #2 confirmed both times that the cart had been left unlocked while unattended. Medication storage areas also contained expired medications and supplies, and one medication was stored contrary to the manufacturer's temperature instructions. On 08/13/25, Nitroglycerin on a medication cart had an expiration date of 06/25. In the medication storage room, surveyors found three boxes of Influenza vaccines expired 06/30/25, two Uro-secure devices expired 09/30/24, two IV secondary administration sets expired 08/12/25, a bottle of Magnesium oxide 400 mg expired 07/2025, and ten tubes of Hemorrhoidal cream expired 08/25. A bottle of Acidophilus opened on 06/15/25 was labeled to be refrigerated after opening but was found on the shelf in the medication room instead of being refrigerated, and LPN #1 confirmed the expired items should be disposed of and the unrefrigerated medication should have been refrigerated.
Menu Items Not Followed and Resident Meal Choices Not Honored
Penalty
Summary
The facility failed to ensure residents’ nutritional needs and preferences were met when the food served did not match the posted menu and residents were not given the opportunity to select their meal choices in advance. The posted lunch menu for 08/10/25 listed herb crusted roast pork with a dinner roll, baked potato, green beans and onions, with meatballs as the alternate item and cinnamon cheesecake for dessert, but the meal observed was turkey and mashed potatoes or quiche, dinner roll, and tater tots, with no dessert served. The Dietary Manager confirmed the lunch meal served did not match the menu. On 08/10/25, a resident’s meal ticket indicated egg and sausage casserole with white toast, sliced pears, and oven browned potatoes, but the meal observed was eggs with cheese, a white dinner roll, tater tots, and peaches. The resident stated he does not look at the meal tickets or menus because the facility does not follow it. On 08/11/25, the posted lunch menu listed a burrito, broccoli salad, dinner roll, and mixed fruit cup, but the meal served included a burrito, peas, bread slices, and sliced bananas instead. The Dietary Manager stated the menu is not always followed and staff do their best to make comparable food items.
Unsanitary kitchen conditions and improper food storage
Penalty
Summary
The kitchen was found to be unsanitary during observation on 08/10/25 at 10:00 am. The ice machine was approximately three quarters full of ice and had dried residue on the inside, along with what appeared to be dried food particles and splatters on the outside. The coffee, juice, and tea machines were visibly dirty with dried spills and splatters on them. The floor throughout the kitchen was visibly dirty with trash, food particles, dried fluid spills, and dirt, and the walls and backsplash behind the sink and stove were visibly dirty with spills and splatters. The countertops were also visibly soiled with food particles, trash, and dried spills and splatters. The walk-in refrigerator had a sign on the door stating it was out of service, yet it contained two boxes of molded biscuits, a box of individual portioned packages of whipped butter spread, one box of corn tortillas, one box of hot dog buns, two gallons of water, and one half-used gallon of sweet and sour sauce. During an interview at 10:41 am, the Dietary Manager confirmed that the ice machine, coffee machine, juice machine, and tea machines were visibly dirty, that the kitchen floors were visibly dirty, and that the food items stored in the walk-in refrigerator were not stored properly and should be.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to develop and implement an ongoing infection prevention and control program by not keeping Enhanced Barrier Precaution signs visible outside rooms with precautions and by not ensuring hand sanitizing or hand washing occurred during resident meal service. During observation, PPE was hanging on the doors outside rooms 200, 202, 205, 215, 217, and 222, but the Enhanced Barrier precaution signs for those rooms were tucked behind yellow PPE gowns and were not visible. The facility’s infection control policies referenced CDC guidance, and CDC guidance reviewed by surveyors stated that EBP signs should be displayed outside the room door and indicate the type of precaution and PPE to be used during high-contact resident care activities. During lunch dining service observation, CNA #5 touched a resident’s right arm/shoulder, picked up a cup from the floor, opened the kitchen door leading to the dirty dishes section, placed the cup in the dirty dish container, and then served lunch to a resident without sanitizing or washing her hands. CNA #4 touched her head/hair and neck/shoulder while talking and then served lunch to another resident without sanitizing or washing her hands. An RN later confirmed that staff should sanitize or wash their hands after touching dirty surfaces and handling food trays.
Missing COVID-19 Vaccination Documentation for 4 CNAs
Penalty
Summary
The facility failed to maintain documentation related to staff COVID-19 vaccinations for 4 of 4 staff members reviewed: CNA #1, CNA #2, CNA #3, and CNA #4. Based on record review, each of these personnel files did not contain COVID-19 immunization history, documentation that the staff member received education about the COVID-19 vaccine, or documentation that the staff member was given the opportunity to refuse or accept the vaccine. For CNA #1, CNA #2, CNA #3, and CNA #4, the personnel records lacked evidence that they were educated on the benefits and potential risks associated with the COVID-19 vaccine, offered the vaccine or information on how to obtain it, or provided an opportunity to decline vaccination. The report states that this deficient practice could likely result in staff not having the knowledge or opportunity to get needed vaccinations.
Kitchen Equipment Not Kept in Safe Operating Condition
Penalty
Summary
Essential kitchen equipment was not kept in safe operating condition. During an observation on 08/10/25 at 10:00 am, the cleaning solution dispenser above the three-compartment sink had a cloth tied around it with water pouring from it into the sink. The walk-in refrigerator had a sign on the door stating it was out of service, yet it contained two boxes of molded biscuits, a box of individual portion packages of whipped butter spread, one box of corn tortillas, one box of hot dog buns, two gallons of water, and one half used gallon of sweet and sour sauce. The bottom vent of the freezer in the kitchen fell off when the door was opened, exposing the wires and mechanical parts under the freezer. During an interview at 10:41 am, the Dietary Manager confirmed the cleaning solution dispenser was pouring water from the hose and stated it was not supposed to. She also stated the walk-in refrigerator was not working and was being used for storage. The Dietary Manager confirmed the walk-in refrigerator contained two boxes of molded biscuits that needed to be disposed of and stated the food items stored in the walk-in did not meet her expectations because the unit was broken and being used inappropriately to store food items.
Failure to Timely Submit Abuse and Neglect Investigation Reports
Penalty
Summary
The facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 2 residents reviewed for abuse or neglect. For resident #32, the facility received an extension for the five-day report after an incident dated 05/15/25, making the due date 05/27/25, but the report was not completed and submitted until 06/09/25. For resident #64, the facility received an extension for the five-day report after an incident dated 05/12/25, making the due date 05/28/25, but the report was not completed and submitted until 06/02/25. During interview, the Administrator stated she was the facility's Incident Coordinator and confirmed it was her responsibility to ensure allegations of abuse and neglect were investigated and the follow-up report was submitted within five days, and she confirmed this did not happen for either incident.
Unnecessary Wander Guard Used for Resident Without Wandering Risk
Penalty
Summary
The facility failed to keep a resident free from the use of a physical restraint when staff continued to use a wander guard for a resident who no longer needed it. The resident was admitted with diagnoses including dementia with mood disturbance, thyrotoxicosis, GERD, long-term insulin use, history of falling, and need for assistance with personal care. His MDS dated 06/18/25 showed a BIMS score of 12 and indicated he was not at risk for wandering. Record review of the resident’s elopement evaluation dated 07/23/25 showed he had no history of elopement and had not attempted to leave the facility without informing staff. Despite this, observation on 08/13/25 showed the resident wearing a wander guard on his right ankle, while the current physician order dated 02/10/25 directed a wander guard on his left ankle for poor safety awareness. During interviews, the resident stated he was not sure why he had the wander guard on, and the Administrator, an LPN, and a CRC each stated he did not exhibit behaviors or signs of wandering and should not have had a wander guard in place.
Care Plan Missing Elopement Risk and Wander Guard
Penalty
Summary
The facility failed to ensure that R #32’s care plan was revised to include elopement risk and the use of a wander guard. R #32 was admitted with diagnoses including other pulmonary embolism, bipolar disorder, schizoaffective disorder, and essential hypertension. A progress note dated 07/01/25 documented that the resident’s guardian was contacted and approved the use of a wander guard due to increased elopement behaviors. On 08/10/25, observation showed a wander guard on the resident’s wheelchair, but the care plan dated 04/08/25 did not contain any indication of elopement risk or the use of a wander guard. During interview on 08/13/25, LPN #1 confirmed that the resident used a wander guard because of increased elopement behaviors and that the care plan did not include this information.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing information every day at the beginning of the shift. The staffing data sheet observed at the main entrance on 08/10/25 at 10:00 am was dated 08/08/25, rather than the current date, and the Administrator later confirmed on 08/13/25 at 1:22 pm that the nursing staffing data sheet should be posted daily and it was not. The report states the posting was required to include the facility name, current date, total number and actual hours worked by RN, LPN, and CNA staff directly responsible for resident care per shift, and resident census.
Significant Medication Error: Ordered Treatments Not Provided but Documented as Completed
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors by not administering medications as ordered. The resident was admitted with diagnoses of peripheral vascular disease and heart failure. During observation and interview, the resident had not received the ordered Lidocaine external patch and had no wraps on her legs. Current physician orders directed that a Lidocaine external patch be applied to the upper back in the morning for back pain and that both legs be wrapped with ACE bandages daily at 6:00 am for edema. However, the MAR showed that an LVN signed that both the patch was applied and the bilateral leg wraps were completed. The Unit Manager confirmed that the resident had not received the patch or the leg wraps and that the LVN had documented the orders as completed when they were not.
Failure to Investigate and Communicate Grievance Outcomes
Penalty
Summary
The facility failed to conduct in-depth investigations, correct grievance allegations, and notify residents of the outcomes of their grievances, as required by its own policy. Multiple residents reported filing several grievances regarding issues such as food and showers, but stated they never received any outcomes or responses. Review of the facility's Grievance/Concern policy confirmed that staff are required to document all grievances and provide responses to residents. During interviews, the Administrator was unable to provide evidence of grievances, investigations, corrective actions, or communication of outcomes, citing that the previous Social Services Director had taken the grievance binder and a new binder was only started recently.
Medication and Treatment Carts Found Unlocked
Penalty
Summary
Surveyors observed that both a medication cart and a treatment cart were left unlocked and unattended in the facility. On two separate occasions, the medication cart was found unlocked by a resident room and the treatment cart was found unlocked near the nurse's station. Interviews with two LPNs confirmed that the carts were not secured at the time of observation. The Director of Nursing also stated that all medication carts should be locked when unattended. These findings indicate that the facility failed to ensure that drugs and biologicals were stored in locked compartments as required for all 62 residents identified in the facility census. No specific residents were identified as being directly involved or affected at the time of the observations, and no additional medical history or resident conditions were noted in the report.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature, as evidenced by record review, interviews, and direct observation. One resident, who was cognitively intact and had multiple medical diagnoses including spinal stenosis, diabetes, depression, and chronic heart failure, reported that the food did not taste good, was often served cold when it should have been hot, and that the facility did not follow the posted menu. Photographic evidence provided by the resident showed multiple instances where the food served did not match the items listed on the meal tickets, with substitutions and omissions occurring repeatedly across several meals. Another resident also reported that hot food was served cold and described the food as inedible, leading him to purchase and store his own food in his room. During a lunch meal observation, the internal temperatures of chicken and pizza served to residents were measured at 109.3°F and 112.6°F, respectively, which were confirmed by both a CNA and a dietary aide to be below appropriate serving temperatures. These findings demonstrate a consistent failure to serve meals according to the planned menu and at safe, appetizing temperatures.
Failure to Maintain Homelike Environment and Minimize Overhead Paging
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in the 200-hall. Observations revealed peeling and chipped paint on the walls throughout the 200-hall, and a section of wall near the therapy entrance that was not repainted to match the surrounding area after an object was removed. Additionally, the handrails in the 200-hall appeared worn and in need of repair or refinishing. These physical deficiencies were directly observed during a facility walkthrough. The facility also used an overhead paging system to announce phone calls for staff and to call staff members and maintenance to the office. Multiple announcements were made over the paging system during the surveyor's observations. During an interview, the Administrator confirmed that the environment was not as comfortable and homelike as desired, acknowledging the issues identified.
Lack of Documentation for Abuse and Neglect Investigations
Penalty
Summary
The facility failed to maintain evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. During an interview, the Administrator stated that there was no documentation of any investigations conducted since the beginning of the year because the previous Social Services Director took the Reportable Binder, which contained all investigation records, upon leaving the facility. As a result, there was a gap in documentation and evidence of investigations for several months, affecting the ability to demonstrate that allegations were properly addressed for all 62 residents in the facility during that period.
Failure to Maintain Accurate and Updated Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were accurate and up to date, as required. For one resident, the care plan listed a do not resuscitate (DNR) code status, while the most current New Mexico Orders for Scope and Treatment (MOST) form indicated an attempt resuscitation code status. This discrepancy was not corrected after the resident returned from the hospital, as confirmed by the Director of Nursing (DON) during an interview. The resident's medical history included spinal stenosis, type 2 diabetes mellitus with hyperglycemia, depression, and chronic diastolic heart failure. The resident was also assessed as cognitively intact. For the second resident, the care plan did not reflect updated preferences for bathing frequency, as the Bathing Preference Sheet was changed to once a week, but the care plan still indicated a choice between bed baths or showers twice per week. Additionally, the care plan listed a DNR code status, while the MOST form indicated an attempt resuscitation code status. The DON confirmed that the care plan should have been revised to match the most current MOST form and to include a care plan for refusals of care, but these updates were not made.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and showering, for a dependent resident. Record review of the resident's documentation from 11/28/24 through 04/28/25 showed that the resident only received bed baths on several occasions, with no evidence of showers or full bathing being provided during this period. This lack of proper bathing assistance was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to provide these services.
Failure to Implement and Document Fall Prevention and Post-Fall Interventions
Penalty
Summary
Staff failed to implement and document necessary fall prevention and post-fall interventions for two residents with significant cognitive and physical impairments. One resident, with diagnoses including dementia, major depressive disorder with psychotic symptoms, reduced mobility, and delusional disorders, required substantial assistance with transfers and had a history of falls. Despite the resident's guardian requesting the bed be kept in a low position and a fall mat be used, neither intervention was in place. The resident's care plan did not include these interventions, and after an unwitnessed fall, there was no evidence that neurochecks were performed. The Director of Nursing confirmed these interventions were not implemented as required. Another resident, also with severe cognitive impairment and a history of falls, had multiple falls documented without adequate information regarding the cause or circumstances of the incidents. The care plan identified the resident as being at risk for falls and directed staff to monitor for changes that could increase fall risk. However, documentation was insufficient to determine the cause of the falls, and neurochecks were not completed following the incidents. The Director of Nursing acknowledged the lack of documentation and post-fall assessments.
Failure to Change and Label Oxygen Tubing per Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents who required oxygen therapy. For each resident, observations revealed that the oxygen concentrator tubing either lacked a label indicating when it was last changed or was not changed as ordered. In one instance, a resident was found using an oxygen concentrator with another resident's name on the attached bag, and there was no documentation of when the tubing was last replaced. The Director of Nursing (DON) confirmed these findings and stated that her expectation was for each resident to have a dedicated oxygen concentrator and for tubing to be changed and labeled as ordered. Medical records for the affected residents showed diagnoses including chronic obstructive pulmonary disease (COPD), quadriplegia, type 2 diabetes mellitus, morbid obesity, acute and chronic respiratory failure, essential hypertension, obstructive sleep apnea, and chronic congestive heart failure. Despite having medical orders specifying the frequency for changing oxygen concentrator tubing and labeling it with the date, staff did not consistently follow these orders, as evidenced by the lack of labeling and uncertainty regarding equipment assignment.
Failure to Update and Reconcile Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive and New Mexico Orders for Scope of Treatment (MOST) form were consistent with the physician's orders documented in the electronic health record (EHR). Record review showed that the resident's physician orders indicated a Do Not Resuscitate (DNR) status, while the current advance directive and MOST form reflected a Full Code status. During an interview, the Director of Nursing (DON) confirmed that the resident's code status should be Full Code, not DNR, highlighting the inaccuracy and lack of update in the resident's medical chart. This discrepancy was identified for one of two residents reviewed for advance directives.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who was admitted following hip surgery. Upon admission, the resident had physician's orders for Gabapentin, Norco, and Ibuprofen to manage her pain. However, the facility did not administer any of these medications during her stay. The resident complained of severe pain, rated at an eight on a scale of ten, and requested her prescribed medications. Instead, the nurse offered Tylenol, which was not part of the resident's medication orders, while waiting for the pharmacy delivery. The Medication Administration Record confirmed that no medications were administered to the resident during her stay. The resident's pain was not alleviated, leading her to call 911 for assistance and subsequently discharge herself against medical advice. Interviews with the Director of Nursing and the Assistant Director of Nursing revealed that pain medications should have been available through the facility's medication dispensing systems, such as the Nexus and E-Kit, without waiting for pharmacy delivery. The failure to provide the prescribed pain relief resulted in the resident experiencing significant pain and leaving the facility prematurely.
Deficient Meal Quality and Presentation
Penalty
Summary
The facility failed to ensure that meals served to residents were attractive, palatable, and at a safe and appetizing temperature. Multiple residents expressed dissatisfaction with the food, describing it as lacking flavor, being lukewarm, unrecognizable, and sometimes cold. Observations in the kitchen revealed that food items such as chicken tenders and mixed vegetables were not prepared to a satisfactory standard, with the chicken appearing overcooked and dry, and the vegetables being overly soft. Additionally, grievances from residents highlighted issues such as soggy sandwiches, overcooked pasta, and finding hair in food, indicating ongoing concerns with meal quality. Interviews with residents and a family member further emphasized the dissatisfaction with the facility's food, with complaints about the food's appearance, taste, and temperature. A staff member anonymously confirmed that there were ongoing complaints about the food quality. The grievances reviewed also included a complaint about a blueberry cobbler that was not fully cooked, causing a resident to feel sick. These findings suggest a pattern of inadequate meal preparation and presentation, impacting residents' dining experience and potentially their nutritional intake.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident, leading to a deficiency in care. The resident was admitted with multiple diagnoses, including a Stage 3 pressure ulcer, Type 2 diabetes mellitus, and long-term use of insulin and anticoagulants. Despite these conditions, the care plan was not updated to include necessary interventions for wound care until 25 days after admission. This delay in updating the care plan did not meet the expectations of the Director of Nursing, who stated that the comprehensive care plan should have been completed within seven days of the comprehensive assessment. The resident's care plan initially lacked interventions for the treatment of pressure ulcers, which were only added after a significant delay. The Director of Nursing confirmed that the care plan was not comprehensive, as it failed to include needed interventions for pressure ulcers, including a Stage 3 ulcer to the coccyx and a surgical incision to the back of the neck upon admission, as well as in-house acquired wounds such as a Stage 3 ulcer to the left heel and a deep tissue injury to the right heel. This oversight in care planning could potentially lead to a worsening of existing wounds or the development of new ones.
Incomplete Discharge Summary and Communication Failure
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, which included a recapitulation of the resident's course of treatment and a reconciliation of all medications at the time of discharge. The resident was admitted with multiple diagnoses, including a fracture of the humerus, type 2 diabetes, long-term use of insulin and anticoagulants, and pressure ulcers. Upon discharge, the Medication Administration Record (MAR) provided was outdated, listing medications that had been discontinued according to the resident's History and Physical assessment. Additionally, the discharge plan lacked any current medication orders, recommendations for care, or updates on the resident's ability to use his arm for activities. The receiving facility's staff encountered difficulties due to the lack of communication and incomplete discharge documentation. The Director of Nursing (DON) at the receiving facility reported that they were unsure of the resident's current medication regimen and had to schedule further tests for the resident's arm due to missing information about the fracture. Attempts to contact the discharging facility for clarification were unsuccessful, as the staff did not return calls. The DON at the discharging facility acknowledged the failure to communicate and confirmed that a comprehensive discharge plan was not created for the resident's transfer.
Deficiencies in Water Temperature Management and Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in the dementia care unit. Water temperatures were recorded to be excessively high, reaching up to 125 degrees Fahrenheit, which is above the safe limit of 120 degrees Fahrenheit. This issue affected six residents, all of whom had varying degrees of cognitive impairment, making them particularly vulnerable to the risk of burns. Despite initial adjustments to the water temperature, there was no consistent monitoring or documentation of water temperatures in resident rooms, leading to continued exposure to potential harm. Additionally, the facility failed to provide adequate supervision to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident experienced multiple falls, some resulting in injuries, without proper assessment or implementation of effective interventions to prevent future incidents. The resident's care plan included interventions such as a low bed and fall mats, but these measures were insufficient, as evidenced by the resident's repeated falls and injuries. The facility's documentation was lacking in assessments and investigations into the causes of the falls and injuries, and there was no evidence of additional interventions being put in place. The facility's inaction in both maintaining safe water temperatures and preventing falls placed residents at risk of serious injury. The lack of consistent monitoring and documentation, as well as the failure to implement effective interventions, highlights significant deficiencies in the facility's ability to provide a safe environment for its residents. These deficiencies were identified by surveyors, who noted the potential for serious harm due to the facility's failures.
Removal Plan
- Implementation of a removal plan through observations of water temperatures
- Review of education documentation
- Interviews with staff and the professional plumber
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage temperatures, as observed during a survey. The walk-in refrigerator was found to be at 49 degrees Fahrenheit, which is above the recommended temperature range of 35 to 40 degrees Fahrenheit. This refrigerator contained various perishable items, including roasts, lettuce, mayonnaise, and potatoes, which were not stored at the required temperature of 41 degrees Fahrenheit or below. The Dietary Manager acknowledged the issue, stating that the refrigerator had been malfunctioning for four months, and a work order had been submitted for repairs. Additionally, the lettuce was noted to be turning brown, and the facility's policy on cold food storage was not adhered to. The facility also failed to ensure proper hand hygiene practices in the kitchen. Cook1 was observed using a quaternary sanitizer to clean her hands between handling soiled and clean dishes, which is not an approved method for hand sanitization. The District Manager of the contracted dietary service confirmed that this was not the correct procedure, and the facility's handwashing policy required washing hands after contact with soiled equipment. The sanitizer used was intended for surface disinfection, not for hand sanitization, as per the manufacturer's instructions. Additional observations revealed unsanitary conditions in the kitchen, including soiled containers and sticky cabinet doors. Expired food items were found in both the main kitchen and the dementia care unit's refrigerator/freezer. These included cottage cheese, Knorr Vegetable Base, and various frozen dinners, all past their use-by dates. The facility's policy on safe food handling from visitors was not followed, as expired items were not discarded, and the storage area was not monitored daily as required.
Failure to Maintain Safe Refrigerator Temperature
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at a safe operating temperature, which had the potential to affect all 59 residents by risking food-borne illness. During an observation, the refrigerator's temperature was recorded at 49 degrees Fahrenheit, which is above the safe temperature range for storing perishable foods. The refrigerator contained various food items, including roasts, lettuce, mayonnaise, alfredo sauce, potatoes, margarine, and angel food cake. The Dietary Manager confirmed the temperature issue and acknowledged that the refrigerator had been problematic for the past four months. Despite submitting a high-priority work order to the Maintenance Director, the issue remained unresolved. The facility's policy requires perishable foods to be stored at 41 degrees Fahrenheit or below, except during preparation and service. However, the refrigerator's temperature exceeded this limit, with food items like potatoes and lettuce also recorded at unsafe temperatures. The Maintenance Director admitted to receiving the work order but cited difficulties in securing vendors to address the problem. This inaction led to the continued use of a malfunctioning refrigerator, posing a risk to the residents' health due to improper food storage.
Failure to Provide Ordered Restorative Services
Penalty
Summary
The facility failed to provide restorative services as ordered by the physician for five residents, leading to potential avoidable decline in their functional abilities. Resident 37, diagnosed with quadriplegia and contractures, was supposed to receive passive range of motion exercises five times a week. However, records showed that these exercises were only provided 11 out of 20 possible times, and the resident reported not receiving the services as expected. Similarly, Resident 54, with diagnoses including schizophrenia and dementia, was to receive active range of motion exercises seven times a week but only received services on 12 out of 25 days. The resident indicated that the staff responsible for her therapy was often unavailable due to other duties. Resident 46, with conditions such as spinal stenosis and diabetes, was ordered to have bilateral lower extremity exercises five times a week but only received them seven to eight times in July, with two refusals documented. Resident 11, who had kidney failure and muscle weakness, was supposed to resume restorative nursing with exercises three times a week but had no documented evidence of receiving any services. Lastly, Resident 34, with schizophrenia and muscle weakness, was to have hand carrots applied daily, but there was no physician's order for this, and the resident reported having to apply them herself when possible. Interviews with staff revealed that the lack of restorative services was due to staffing issues, particularly with CNA1, who was also responsible for driving the facility's van, leaving no time for restorative duties. The MDS Coordinator acknowledged awareness of the gaps in care and had raised concerns with management. The facility's policy on restorative nursing emphasized the importance of maintaining residents' functional abilities, but the lack of consistent restorative services as ordered was evident in the documentation and resident reports.
Lack of Activities for Dementia Care Unit Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and interests of residents on the dementia care unit, affecting five out of six residents reviewed. These residents, who were severely cognitively impaired, were observed without engagement in meaningful activities, despite their care plans indicating the importance of such activities. The care plans for these residents included interventions like encouraging participation in activities such as bingo, arts and crafts, and pet visits, but these were not implemented. Observations over several days revealed that residents were left to wander the halls or sit idly without any structured activities. Staff interviews confirmed the absence of an Activity Aide on the dementia care unit, which resulted in no activities being conducted. The lack of activities led to residents exhibiting behaviors such as repeatedly attempting to open locked doors and expressing confusion about meal times. The Activity Director and the Administrator acknowledged the lack of activities, citing staffing issues as the reason. The facility's policy emphasized the importance of a person-centered recreation program to maintain and improve residents' well-being, but this was not adhered to. The deficiency was attributed to the absence of dedicated staff to facilitate activities, which had not been consistently provided since January 2024, except for a brief period in June 2024.
Fly Infestation in Facility
Penalty
Summary
The facility failed to maintain an environment free of flies, which were observed in various areas including resident rooms, dining rooms, hallways, and the therapy room. This deficiency was noted during observations and interviews with residents and staff. Residents reported that flies were a persistent issue, particularly during mealtimes, and were seen landing on residents and their food. The presence of flies was a concern for residents, some of whom were unable to swat them away due to physical limitations. Several residents, including those with dementia, spinal stenosis, atrial fibrillation, quadriplegia, and traumatic brain injury, were affected by the fly infestation. These residents were cognitively intact and expressed their dissatisfaction with the fly problem. One resident mentioned that the flies had been an issue since their admission, while another resident noted that flies landed on a sore on their leg. The problem was exacerbated by a broken fly curtain at the smoking area door, which had been in disrepair for at least ten months. The Maintenance Director acknowledged the fly problem and attributed it partly to the broken fly curtain. The facility had a contract with a pest control company that sprayed outside every two weeks, but the use of pest spray inside the building was not possible. The Director of Nursing also acknowledged the issue, stating that flies were a constant problem despite efforts to keep doors closed and maintain cleanliness. The facility's policy on infection control and pest management was reviewed, indicating a commitment to providing a pest-free environment through contracted services.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure the participation of two residents in the development and implementation of their person-centered care plans. Resident 32, who was cognitively intact with a BIMS score of 15, was not involved in her care plan meeting, and there was no documentation to show she was invited or attended. Despite the facility's policy requiring resident involvement, the Social Service Director (SSD) could not provide evidence of an invitation or attendance for Resident 32. Similarly, Resident 48, also cognitively intact with a BIMS score of 15, reported not having attended a care plan meeting since admission. Although a letter was provided for a care plan conference, there was no documented evidence of Resident 48's invitation or attendance at any care plan meetings. The facility's policy emphasizes the resident's right to participate in their care planning, but the SSD was unable to provide documentation supporting the residents' involvement.
Inadequate Infection Control During Medication Administration and Wound Care
Penalty
Summary
The facility failed to administer medications in a manner that prevents cross-contamination for five residents during a medication pass. An LPN was observed not performing hand hygiene between resident contacts while administering medications, including blood pressure checks and handling inhalers. The LPN confirmed during an interview that she did not perform hand hygiene between residents, which contradicts the facility's policy requiring hand hygiene before and after resident care and contact with the resident's environment. The Director of Nursing also stated that hand sanitizer should be used after contact with each resident, and hands should be washed after every three resident contacts or when using liquids or injections. Additionally, the facility failed to complete wound care in a manner that prevents cross-contamination for a resident with pressure ulcers. An LPN was observed not changing gloves or performing hand hygiene between steps of the wound care process, such as cleaning the wound, applying medication, and dressing the wound. The LPN confirmed during an interview that she did not follow infection control standards, which increased the risk of infection for the resident. The facility's policy requires clean gloves to be applied, old dressings to be removed and discarded, and new gloves to be used when cleansing the wound and applying medication.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff, including Registered Nurses, Licensed Nurses, and Nursing Assistants, as required by federal and state regulations. This deficiency was observed during multiple visits, where no nurse staffing information was prominently displayed and accessible for patients, visitors, and staff. During interviews, the Administrator and the Director of Nursing (DON) acknowledged the issue, citing problems with the Velcro not sticking to the wall and the glass case not holding the sheets. Instead, the staffing sheets were kept in a box beside the business office door and in a drawer in the DON's office, making them inaccessible for review. This failure had the potential to affect all 59 residents residing at the facility and any visitors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 53 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clovis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Retirement Ranches Inc. | 0.6 mi | ★★★★★ | 9 | 0 |
| Clovis Healthcare And Rehabilitation Center | 2.4 mi | ★★★★★ | 23 | 0 |
| Farwell Care And Rehabilitation Center | 10.5 mi | ★★★★★ | 21 | 0 |
| Coronado Care Center | 18.7 mi | ★★★★★ | 0 | 0 |
| Park View Nursing Care Center | 30.5 mi | ★★★★★ | 24 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.