The Neighborhood In Rio Rancho
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Rancho, New Mexico.
- Location
- 900 Loma Colorado Blvd Ne, Rio Rancho, New Mexico 87124
- CMS Provider Number
- 325130
- Inspections on file
- 25
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at The Neighborhood In Rio Rancho during CMS and state inspections, most recent first.
The facility failed to protect a resident from exposure to physical and mental abuse when a CNA and an RN engaged in a verbal and physical altercation in the resident’s room and on the resident’s bed while the resident was present. The resident, who had multiple serious conditions including a right femur fracture, COPD, DM2, HTN, pulmonary embolism with acute cor pulmonale, generalized muscle weakness, and a cognitive communication deficit, was awakened by noise and movement of the bed as the struggle occurred. Police and staff accounts indicated that the confrontation escalated from the hallway into the room, with the CNA and RN physically fighting next to and on the bed, and furniture in the room being moved. The resident later reported to a psychiatrist that she witnessed the altercation, felt frightened, anxious, and depressed, and stated she did not feel safe.
A CNA failed to prevent abuse of a dependent resident with multiple medical conditions by handling her forcefully and aggressively during care, contrary to the care plan requiring two-person assistance. The incident was captured on video, showing the resident appearing scared and confused, and was reported by the family. The CNA did not request help from available staff and later admitted to using excessive force.
Two residents experienced deficiencies in care when necessary fall assessments and interventions were not completed after a fall, and when a Hoyer lift transfer was performed by only one staff member instead of the required two. One resident with multiple medical conditions did not receive post-fall assessments or care plan updates, while another dependent resident was transferred alone despite orders for two-person assistance. The DON confirmed that standard procedures were not followed in both cases.
A resident with dementia and dysphagia did not have accurate or consistent weights recorded as ordered, with missed and incorrect entries not followed by timely re-weighs. Staff interviews confirmed ongoing problems with obtaining weights and reliable meal intake documentation. These failures led to a delay in identifying significant weight loss and in starting a nutritional supplement.
The facility did not ensure accurate and complete medical records for two residents, including inconsistent documentation of physical abilities, lack of fall assessments and care plan updates after a fall, missing ADL entries for multiple days and shifts, incomplete shower records for a hospice resident, and inaccurate meal intake documentation. Staff interviews confirmed that CNAs sometimes documented for residents they did not care for, and required documentation was not consistently completed as expected.
A resident with multiple chronic conditions experienced a decline and a change in diet after returning from the hospital. Although the legal guardian was listed as the primary contact, staff failed to notify the guardian of these changes, with documentation and interviews confirming the lack of communication. Instead, a different family member was contacted, and the guardian remained unaware of the resident's updated condition and care needs.
The facility did not provide orientation or verify competencies for agency CNAs and RNs before they began working, relying solely on the contracting agency for training and background checks. This led to incidents where a CNA was unaware of a resident's need for assistance with dressing, causing distress, and an RN sent a hospice patient to the hospital without knowledge of their hospice status. Staff interviews and record reviews confirmed the absence of facility-led orientation and incomplete training records for agency staff.
Two residents receiving hospice care were improperly billed by the facility for items and services such as oxygen equipment, medications, wipes, and adult briefs, which should have been covered by hospice. The billing specialist confirmed these charges were made while waiting for clarification on hospice-covered items.
A resident with severe cognitive impairment developed new wounds, and the POA was not notified of these injuries. The POA discovered the injuries during a visit and was unable to obtain information from staff or records about the cause. The DON confirmed that notification did not occur as required.
The facility did not update care plans for three residents after significant changes in their care needs, including a fall resulting in a hip fracture and the initiation of hospice services. Despite documentation and confirmation from the DON, care plans were not revised to include new interventions or reflect hospice care, leaving important changes in condition unaddressed.
Two residents did not have proper documentation or coordination of hospice services, including missing hospice orders, lack of qualifying diagnoses, and absent hospice plans of care. In one case, staff failed to notify the hospice agency of a significant change in condition, and in both cases, the Director of Nursing confirmed that required hospice documentation and care planning were not in place.
A resident with multiple diagnoses, including vascular dementia and behavioral disturbances, was involved in an incident where staff observed aggressive behavior. However, the annual MDS assessment did not document any behavioral symptoms, and the MDS Coordinator confirmed the assessment was inaccurate.
A resident with multiple medical conditions, requiring assistance for transfers, fell and was injured when a Hoyer lift sling broke during a transfer. Only one CNA was present, despite the requirement for two staff members. The facility acknowledged negligence in not following proper procedures.
A resident with multiple health conditions, including muscle weakness and reduced mobility, fell and sustained injuries when a Hoyer sling broke during a transfer. The facility's maintenance policy required regular equipment inspections, but the Administrator confirmed that maintenance staff had not checked the sling prior to the incident, contributing to the equipment failure.
The facility failed to store food in accordance with professional standards when staff stored expired food in the walk-in refrigerator. During an observation, three packages of tofu with an expiration date were found in the refrigerator. The chef acknowledged that expired tofu should be discarded, and the Director of Dining Services confirmed that kitchen staff should check the refrigerator daily for expired foods and discard them when found.
A facility failed to provide prescribed wound care for a resident with malignant melanoma and a surgical removal of the right breast. The resident's MAR indicated daily wound care, but staff completed the treatment only two out of ten times. Interviews revealed inconsistencies and a lack of clarity regarding wound care responsibilities, leading to the resident not receiving appropriate and timely care.
The facility failed to ensure proper handling and storage of medications and medical supplies. Loose medications were found in a medication cart, expired supplies were stored with unexpired ones, and fentanyl patches were improperly stored in the medication cart instead of being destroyed immediately.
The facility failed to update the care plan for a resident who was admitted to hospice services. The resident's EMR indicated hospice services began in January, but a review in April showed the care plan lacked this information. The Social Services Director confirmed the care plan should have been updated but was not.
The facility failed to notify the Pharmacist and DON about a morphine spill and a missing fentanyl patch for two residents, leading to improper handling and documentation of medications.
A resident with a history of pneumonia was found with oxygen tubing that had not been changed for over a month. The physician's orders lacked specific instructions on tubing replacement frequency, and a nurse confirmed it should be changed weekly but was not.
A resident fell in the dining room while playing Bingo, and although family members were present, the facility failed to notify the POA and NP. The DON confirmed that staff should always inform the POA of any falls, and the NP confirmed she was not made aware of the incident.
A resident with Parkinson's disease receiving hospice care was incorrectly administered morphine sulfate as a scheduled medication instead of PRN due to a transcription error by an agency nurse. The resident received multiple doses before the mistake was identified and corrected, causing distress to the resident's daughter.
The facility failed to provide necessary behavioral health treatment for a resident diagnosed with dementia and schizophrenia, who exhibited insomnia and aggressive behavior. Despite frequent monitoring and documentation of the resident's agitation and restlessness, no physician orders or behavioral health consults were initiated to address these issues. Interviews with staff revealed awareness of the resident's problems, but no actions were taken to provide appropriate care.
The facility failed to monitor the behaviors of a resident on psychotropic medications, despite documented aggressive and restless behaviors. The Treatment Administration Record lacked sufficient documentation, and staff interviews confirmed the resident's frequent noncompliance and falls. This represents a significant deficiency in care practices.
The facility failed to ensure resident furniture was in operable condition, as evidenced by the continued use of a broken recliner. An observation revealed a recliner with a footrest that did not lock in the elevated position. The DON confirmed that staff had been using a foot stool to keep the footrest elevated and acknowledged that the broken recliner should not have been available for resident use.
Failure to Protect Resident From Staff Altercation in Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment free from abuse when a physical and verbal altercation between two staff members occurred in a resident’s room and on the resident’s bed while the resident was present. The resident had been admitted with multiple serious medical conditions, including a displaced fracture of the right femur, COPD, DM2, HTN, pulmonary embolism with acute cor pulmonale, generalized muscle weakness, and a cognitive communication deficit. An MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. Despite these vulnerabilities, the facility did not prevent staff from engaging in a violent confrontation in the resident’s immediate care environment. According to a police report, a CNA stated that an RN pushed him, and he pushed the RN into a resident room, where he punched her in the face and then restrained her on the ground. The RN reported that she had prior issues with the CNA and that on the night of the incident she observed him yelling in a patient’s room while on the phone with the DON. She stated that after she told him to leave the facility to take the call elsewhere, he approached and punched her multiple times in the face, dragged her by the collar into the resident’s room, and continued the assault on the floor next to the resident’s bed, including placing his knee against her chin and neck. The CNA, in his own account, acknowledged that the physical struggle moved into the resident’s room, that the RN climbed onto the resident’s bed while the resident was still in it and kicked at him, and that a bedside table with a water pitcher was pushed toward him during the altercation. The resident’s psychiatrist reported that the resident described being in bed when she was awakened by noise and feeling her bed move, and that she witnessed the two staff members engaging in a verbal and physical altercation. The psychiatrist stated the resident reported feeling frightened, depressed, anxious, and that she did not feel safe in the facility. The DON later learned that furniture in the resident’s room had been moved during the incident and that the resident was found wrapped in a blanket and being consoled by CNAs. The DON reported that the resident was very anxious and stated she heard loud voices and felt her bed being bumped. These events demonstrate that the facility failed to protect the resident from exposure to physical and mental abuse by not preventing or adequately controlling a staff-on-staff altercation that occurred in the resident’s room and on her bed while she was present.
Failure to Prevent Staff-to-Resident Abuse During Dependent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to prevent abuse of a resident who was dependent on staff for all activities of daily living. The resident had significant medical conditions, including cerebral infarction, type II diabetes, vascular dementia, Parkinson's disease, and dysphagia, and was on hospice care. The resident was unable to complete a cognitive assessment due to impairment and required the use of a Hoyer lift with two-person assistance for transfers, as documented in her care plan. On the evening of the incident, video evidence showed the CNA forcefully and aggressively handling the resident during a brief change and repositioning, including grabbing, pulling, and pushing the resident in a manner that appeared angry and intimidating. The CNA performed these actions alone, despite the care plan requiring two-person assistance with the Hoyer lift. The resident appeared scared and confused during the incident, as observed in the video. The CNA later admitted to using excessive force and acknowledged that the resident was fully dependent on staff for care. Interviews with staff and review of records indicated that the CNA did not request help from another CNA, who was available and routinely assisted with Hoyer transfers. The CNA stated she was not angry but found it difficult to work with the resident due to her lack of mobility. The incident was reported by the resident's family, who observed the abuse via a video camera in the room. The CNA had no prior disciplinary issues, and other staff reported no previous concerns about her conduct. The incident was confirmed through video review and staff interviews.
Failure to Complete Fall Assessments and Ensure Proper Hoyer Lift Use
Penalty
Summary
The facility failed to complete necessary assessments, open a risk management report, create interventions for a fall, and use two staff when operating a Hoyer lift for two residents reviewed for falls. In the first case, a resident with dementia, dysphagia, frontal lobe deficit, hypertension, and a cardiac pacemaker experienced a fall. The resident was found on the floor next to her bed, was awake and alert, and had no obvious injury. Despite this incident, there was no fall assessment, no neurological checks, no change in condition assessment, no post-fall assessment, and no interventions documented for the fall. The care plan did not include any focus or intervention for the fall until a month later, after a second fall occurred. The resident's son confirmed that no interventions were implemented following the initial fall, and staff interviews revealed that standard procedures for post-fall assessment and intervention were not followed in this instance. In the second case, a resident with cerebral infarction, type II diabetes, vascular dementia, Parkinson's disease, and dysphagia was dependent on staff for all activities of daily living and required the use of a Hoyer lift with two-person assistance for transfers. The care plan and physician orders specified that two staff members were required for all Hoyer lift transfers. However, a CNA admitted to transferring the resident alone using the Hoyer lift because her coworker was busy with other residents. Other staff confirmed that the resident required two-person assistance for all transfers and that the proper procedure was not followed during this incident. Interviews with the Director of Nursing confirmed that the required assessments and interventions were not completed for the first resident's fall and that the second resident was transferred using the Hoyer lift by only one staff member, contrary to care plan and physician orders. These failures represent deficiencies in ensuring the area was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.
Failure to Obtain Accurate Weights Delays Nutritional Intervention
Penalty
Summary
The facility failed to obtain accurate and consistent weights for a resident with dementia, dysphagia, and a history of cerebral infarction, as required by physician orders. The resident was to be weighed on admission, then weekly for four weeks, and subsequently every Thursday for routine monitoring. However, the weight log showed missing and inaccurate entries, including a documented error that was not followed by a re-weigh, and a missed weight on a scheduled date. There was also no physician order for a re-weigh after an inaccurate weight was recorded. These inconsistencies in weight documentation led to a delay in identifying significant weight loss. Interviews with facility staff, including the Nutritional Services Director, Assistant Director of Nursing, Director of Nursing, and Registered Dietician, confirmed ongoing issues with obtaining timely and accurate weights, as well as challenges in getting re-weighs completed. The resident was noted to have refused meals and required assistance with eating, but meal intake documentation was found to be unreliable. The delay in obtaining accurate weights contributed to a delay in providing a nutritional supplement, which was only ordered after a significant weight loss was finally documented.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three residents reviewed, resulting in multiple documentation deficiencies. For one resident with diagnoses including dementia, dysphagia, and frontal lobe deficit, the history and physical documented independent movement of all extremities, while the Minimum Data Set indicated upper and lower extremity impairment on one side and a need for full assistance with daily activities. Additionally, after this resident experienced a fall, there was no fall assessment, neuro checks, change in condition documentation, post-fall assessment, or care plan interventions related to the incident, despite the resident's family being notified of the fall. Further review revealed significant gaps in the Activities of Daily Living (ADL) documentation for this resident, with multiple days and shifts lacking any entries for essential care tasks such as eating, dressing, and hygiene. For another resident who was on hospice care, the ADL task list showed only sporadic documentation of showers, despite hospice being responsible for providing them on specific days. Meal intake documentation was also found to be inaccurate, with discrepancies between what was charted and what was reported by the CNA who actually assisted the resident. Interviews with staff confirmed that CNAs were sometimes documenting care for residents they did not personally assist, and that required documentation was not consistently completed before the end of each shift. Both the DON and ADON acknowledged these documentation lapses, noting that the ADL task list should be fully completed daily and that only the CNA providing care should document for the resident.
Failure to Notify Guardian of Resident's Change in Condition and Diet
Penalty
Summary
The facility failed to notify the legal guardian of a resident regarding significant changes in the resident's condition and dietary requirements. The resident, who had multiple diagnoses including osteoarthritis, bipolar disorder, type II diabetes, atherosclerosis, and dementia, experienced a decline in condition and a change in diet following a hospital stay. The guardian was listed as the primary emergency contact and responsible party in the resident's records, with contact information clearly documented. Despite this, there was no documentation in the electronic medical record indicating that the guardian was informed of the resident's decline or the change to a puree diet. Interviews with facility staff, including the DON and Social Services Director, revealed that the guardian was not notified of these changes and that staff were unclear about the notification process. The DON stated that the nurse involved did not know who the guardian was and instead notified the resident's grandson. The guardian confirmed during an interview that he was not made aware of the resident's change in condition or diet, and expressed concern about the lack of communication regarding these significant changes.
Failure to Ensure Competency and Orientation of Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that agency nursing staff, including CNAs and RNs, were competent and properly oriented to provide care to residents. Record reviews and staff interviews revealed that agency staff did not receive any training or orientation from the facility prior to starting their shifts. The facility relied on the contracting agency to complete all required verifications and trainings, and did not maintain records of staff training or background checks for agency staff. Multiple staff members, including the administrator, scheduler, and HR, confirmed that no orientation or training was provided to agency staff before they began working with residents. This lack of orientation and competency verification led to specific incidents affecting residents. One resident, with a history of hemiplegia, atherosclerotic heart disease, altered mental status, and other conditions, required substantial assistance with activities of daily living due to left-sided weakness. An agency CNA was unaware of the resident's limitations and instructed the resident to dress herself, resulting in the resident becoming distressed and attempting to strike the CNA. The CNA later admitted to not knowing the resident was unable to dress herself, and her training records showed multiple expired or incomplete trainings, including those related to abuse, dementia care, and essential clinical assessments. Another resident, with diagnoses including heart disease, chronic atrial fibrillation, congestive heart failure, chronic kidney disease, and diabetes, was admitted to hospice care. An agency RN, unaware of the resident's hospice status, sent the resident to the hospital after an episode of aggression and confusion. The administrator confirmed that the nurse was not aware of the hospice status and should not have sent the resident out, further highlighting the lack of orientation and communication regarding residents' care needs.
Improper Billing of Residents for Hospice-Covered Items and Services
Penalty
Summary
The facility failed to prevent charges against residents' personal funds for items and services that should have been covered by hospice, Medicare, or Medicaid. For one resident, after being admitted to hospice, the facility continued to bill the resident for an oxygen concentrator, cannulas, humidifiers, and medications, all of which were related to the resident's terminal diagnosis and confirmed by the hospice agency to be covered under hospice care. The billing specialist acknowledged charging the resident for these items and stated she was waiting for a list of hospice-covered items. Similarly, another resident who was admitted to hospice was billed by the facility for wipes, adult briefs, and a medication, despite these items being potentially covered by hospice. The billing specialist also confirmed these charges and indicated she was awaiting clarification on hospice coverage. These actions resulted in improper charges to residents' personal funds for items and services that should have been billed to the hospice agency.
Failure to Notify POA of Resident Injuries
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for a resident with severe cognitive impairment when injuries or incidents occurred. The resident, who had diagnoses including chronic heart failure, anxiety disorder, insomnia, and adjustment disorder with depressed mood, was found by her POA to have a bandage on her wrist extending to her elbow and a bandaid on her face during a visit. The POA reported not being informed of any new injuries and was unable to obtain information from staff regarding the cause of the injuries. Documentation in the electronic health record indicated a change of condition form listing a skin wound or ulcer, but no cause was provided, and a total body skin assessment revealed two new wounds. Interview with the Director of Nursing confirmed that the POA was not notified of the injuries, despite facility policy requiring notification of POAs when residents are injured. The POA expressed that communication from the facility had declined since a change in management, and staff were unable to provide details about the incident or the injuries. The deficiency was identified through record review and interviews, establishing that the facility did not fulfill its obligation to inform the POA of significant changes in the resident's condition.
Failure to Update Care Plans for Falls and Hospice Services
Penalty
Summary
The facility failed to ensure that care plans were revised and updated for three out of four residents reviewed, specifically in relation to significant changes in their care needs such as falls resulting in injury and the initiation of hospice care. For one resident, after experiencing a fall that resulted in a hip fracture and subsequent hospitalization, the care plan was not updated to reflect the incident or to add new interventions or a fall protocol. The Director of Nursing confirmed that the care plan should have been revised to include these changes but was not. For two other residents, both of whom were admitted to hospice care, the facility did not update their care plans to reflect their new hospice status or to include appropriate interventions for hospice care. Documentation showed that hospice services had begun, and this was confirmed by both the residents' records and the DON, yet the care plans remained unchanged and did not address the residents' current needs related to hospice care. The DON acknowledged that the care plans did not meet expectations for reflecting these significant changes.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services were provided in accordance with professional standards for two out of three residents reviewed. For one resident, there was no documented order for hospice services, and for another, the qualifying diagnosis for hospice care was not clearly established. Additionally, neither resident had a hospice plan of care available in their electronic health records, and the facility did not communicate with the hospice agency regarding a significant change in condition for one of the residents. One resident was admitted to hospice care with an unspecified illness as the diagnosis, and later with COVID as the qualifying diagnosis, which the Director of Nursing (DON) stated did not meet expectations for hospice eligibility. The hospice plan of care was missing from the resident's record, and the care plan was not updated to reflect hospice services when they began. Furthermore, a registered nurse was unaware that the resident was on hospice when the resident was sent to the emergency room, and the hospice agency was not notified of the change in condition until informed by the family. For the second resident, the electronic health record indicated that routine hospice care was to start, but there was no hospice plan of care or order for hospice services documented. The DON confirmed that the resident's record did not contain any information regarding hospice, including a pertinent diagnosis, a coordinated care plan, or inclusion in the agency's care plan. These findings demonstrate a lack of coordination and documentation necessary for the provision of hospice services as required by facility policy and hospice agreements.
Failure to Accurately Assess Resident Behaviors in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident with multiple complex diagnoses, including hemiplegia, atherosclerotic heart disease, altered mental status, major depressive disorder, and vascular dementia. The resident was readmitted after a hospital stay and had a documented history of behavioral disturbances. On review of records, it was found that a police report documented an incident where staff heard a loud scream and observed the resident going after another staff member, indicating behavioral symptoms. Despite this incident, the resident's annual Minimum Data Set (MDS) assessment did not reflect any physical or verbal behavioral symptoms directed towards others. During an interview, the MDS Coordinator confirmed that any changes in behavior should have been reported to her and acknowledged that the annual MDS assessment should have included information on the resident's behaviors, confirming the assessment was not accurate.
Failure to Ensure Proper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was dependent on staff assistance for transfers due to multiple medical conditions, including acute kidney failure, inclusion body myositis, permanent atrial fibrillation, generalized muscle weakness, and reduced mobility. The resident, who was cognitively intact, required the assistance of two or more staff members for transfer activities. However, during a transfer using a Hoyer lift, the sling broke, resulting in the resident falling and sustaining injuries that required hospital treatment. The incident was witnessed, and the resident suffered a skin tear and bruising from the fall. The facility's initial incident report and follow-up documentation revealed that only one CNA was operating the Hoyer lift at the time of the incident, contrary to the requirement for two staff members to assist with such transfers. The administrator confirmed that the sling was not visibly worn, but acknowledged that the proper procedure of having two staff members present was not followed. The facility's follow-up report concluded that there was negligence involved in the incident, as the CNAs did not adhere to the protocol for using the mechanical lift.
Failure to Maintain Safe Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that patient care equipment was in safe operating condition, which resulted in a Hoyer sling breaking and causing a resident to fall and sustain injuries. The resident, who was admitted with multiple diagnoses including acute kidney failure, inclusion body myositis, permanent atrial fibrillation, generalized muscle weakness, and reduced mobility, was dependent on staff assistance for transfers. The incident occurred when the Hoyer sling broke during a transfer, leading to the resident's fall and subsequent transfer to the emergency room for evaluation. The facility's policy required the Maintenance Manager to develop a maintenance schedule and perform regular inspections and testing of equipment. However, the Administrator confirmed that maintenance staff failed to check the condition of the Hoyer sling prior to the incident. Despite the sling not appearing visibly worn at the time of the incident, the lack of documented maintenance checks contributed to the equipment failure. The Administrator was unable to provide information on when the equipment was last inspected, highlighting a lapse in adherence to the facility's maintenance policy.
Expired Food Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards when staff stored expired food in the walk-in refrigerator. During an observation, three packages of tofu with an expiration date were found in the refrigerator. The facility's chef acknowledged that expired tofu should be discarded and not stored. Additionally, the Director of Dining Services confirmed that the kitchen staff should check the refrigerator daily for expired foods and discard them when found. This deficiency had the potential to negatively impact all 47 residents listed on the census provided by the Director of Nursing.
Failure to Provide Prescribed Wound Care
Penalty
Summary
The facility failed to provide quality care by not administering wound care as prescribed for a resident with a history of malignant melanoma and a surgical removal of the right breast. The resident's Medication Administration Record (MAR) indicated that wound care was to be provided daily for a wound on the right breast and every three days for a wound on the front wall of the thorax. However, a review of the MAR from 05/14/24 to 05/23/24 revealed that staff completed the wound care treatment only two out of ten times. Additionally, hospice care notes indicated that hospice provided wound care only once during this period, on 05/14/24, with no further documentation of wound care provided by hospice thereafter. Interviews with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (IDON) revealed inconsistencies and a lack of clarity regarding the responsibility for wound care. The ADON stated that the facility did not have a designated wound care staff and relied on RNs on shift to provide the care. The IDON acknowledged that there were two contradictory orders for wound care, one for daily care and another for care every three days by hospice, and stated that the expectation was for the nurse on the floor, the DON, or the ADON to discontinue one of the orders to avoid confusion. This lack of coordination and adherence to prescribed wound care regimens resulted in the resident not receiving appropriate and timely wound care, potentially leading to discomfort and infection.
Improper Handling and Storage of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure proper handling and storage of medications and medical supplies. During an observation of the 300 hall medication cart, a loose white, circular tablet was found under the medication cards. A Certified Medication Aide confirmed that loose medications should not be present in the cart and that staff should check for loose medications at the beginning of each shift. Additionally, expired medical supplies, including twenty IV start kits and one hundred safety needles, were found stored with unexpired supplies in the 300 hall medication storage room. A Licensed Practical Nurse acknowledged that expired supplies should not be stored with unexpired ones and should be removed by staff and given to the charge nurse or Director of Nursing. The facility also failed to properly handle fentanyl patches. A nurse admitted to placing a removed fentanyl patch in the medication cart until it could be destroyed, citing the unavailability of a second nurse to assist with the destruction. Both the Assistant Director of Nursing and the Director of Nursing confirmed that fentanyl patches should be destroyed immediately upon removal, with two nurses signing and dating a form to document the destruction. They stated that they were always available to assist with this process, and the patches should not be stored in the medication cart.
Failure to Update Care Plan with Hospice Services
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was admitted to hospice services. The resident's Electronic Medical Record (EMR) indicated that hospice services began on January 17, 2024. However, a review of the care plan on April 24, 2024, revealed that it did not include any information about the hospice services. During an interview on May 22, 2024, the facility's Social Services Director confirmed that the care plan should have been updated to reflect the hospice services, but it was not.
Failure to Notify Pharmacist and DON of Medication Issues
Penalty
Summary
The facility failed to meet professional standards of quality when staff did not notify the Pharmacist and the Director of Nursing (DON) about a morphine spill and a missing fentanyl patch for two residents. For the first resident, there was an order for a fentanyl patch to be applied every 72 hours. On one occasion, the nursing staff applied a new patch but could not find the old one. The Assistant Director of Nursing (ADON) and the nurse managers were not aware of this incident, and there was no documentation found regarding the missing patch. The facility's procedure required staff to notify the DON if a patch could not be located, which was not followed in this case. For the second resident, there was an order for morphine concentrate solution to be administered as needed for pain or shortness of breath. The narcotic log sheet indicated that 4 ml of morphine was wasted, but the staff did not notify the Pharmacist or the DON about the spill. The Pharmacist expected to be informed of such incidents and for a new order to be placed, with the old bottle being destroyed. However, the morphine bottle was still found in the medication cart, indicating a failure to follow proper procedures for handling and documenting medication spills.
Failure to Change Oxygen Tubing as Required
Penalty
Summary
The facility failed to meet professional standards of care for a resident requiring respiratory care by not changing the oxygen tubing as needed. The resident, who had a history of pneumonia, was observed with oxygen tubing dated over a month old. The physician's orders did not specify the frequency for changing the tubing, and a nurse confirmed that the tubing should be changed weekly but was not. This oversight could lead to respiratory infections due to dirty or clogged tubing, compromising the resident's oxygen supply.
Failure to Notify POA and NP of Resident's Fall
Penalty
Summary
The facility failed to notify the power of attorney (POA) and the Nurse Practitioner (NP) of a fall experienced by a resident. The resident fell in the dining room while playing Bingo, and although family members were present, the POA and NP were not informed. The Director of Nursing (DON) confirmed that staff should always inform the POA of any falls, even if a family member was present. The NP also confirmed that she was not made aware of the fall, as indicated by the absence of any notes regarding the incident in the resident's medical record.
Failure to Follow Physician's Order for Medication Administration
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with Parkinson's disease who was receiving hospice care. The resident had a PRN order for morphine sulfate to be administered as needed for pain or shortness of breath. However, the order was incorrectly transcribed by an agency nurse as a scheduled medication to be given every four hours. As a result, the resident received morphine at 4:00 pm and 8:00 pm on the first day, and at 12:00 am, 4:00 am, and 8:00 am on the following day, instead of only when needed for pain or shortness of breath. The error was discovered when the resident's daughter called the facility and was informed that her father was resting due to the administration of morphine. The Director of Nursing confirmed that the initial order was for PRN administration, but the agency nurse had entered it incorrectly as a scheduled medication. The resident received three doses of morphine before the mistake was identified and corrected. The nursing notes also indicated that the resident's daughter was extremely upset about the incorrect administration of the medication.
Failure to Provide Behavioral Health Treatment for Resident with Insomnia
Penalty
Summary
The facility failed to provide necessary behavioral health treatment for a resident diagnosed with dementia with agitation and schizophrenia, who was experiencing insomnia. The resident was admitted to the facility and exhibited multiple instances of aggressive and restless behavior, including being combative, verbally abusive, and attempting to self-propel into other residents' rooms. Despite these documented behaviors, the resident did not have any physician orders to address his lack of sleep or nighttime behaviors. Staff frequently monitored the resident and documented his agitation and restlessness, but no behavioral health consult or treatment for insomnia was initiated during his stay at the facility. Interviews with the nursing staff and the Director of Nursing revealed that the resident's insomnia and behavioral issues were known, but no actions were taken to address them. The Nurse Practitioner was unaware of the resident's insomnia issues, and the Director of Nursing confirmed that no referral for a behavioral health consult was made. The resident had previously received behavioral health care at another facility, but this care was not continued at the current facility. This lack of appropriate behavioral health treatment could likely lead to increased agitation, restlessness, and falls for the resident.
Failure to Monitor Resident Behaviors on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident (R #1) who was on psychotropic medications. The resident, diagnosed with dementia with agitation and schizophrenia, exhibited frequent aggressive and restless behaviors, including screaming, kicking, and attempting to get out of bed unassisted. Despite these behaviors being documented in nursing progress notes, the Treatment Administration Record (TAR) did not contain sufficient documentation to indicate that staff monitored these behaviors as required by the physician's orders and care plan. Specifically, the TAR lacked entries for monitoring agitation, yelling, cursing, and combativeness, and staff only documented '0' for behaviors and redirection without further details. The resident's care plan included specific instructions to monitor for side effects of antipsychotic medications and to document any behavioral symptoms every shift. However, the TAR did not reflect consistent monitoring or documentation of the resident's behaviors and responses to medication. Interviews with nursing staff confirmed that the resident was frequently aggressive, restless, and noncompliant, often refusing medications and attempting to leave the unit or get up unassisted, leading to multiple falls. The lack of proper documentation and monitoring of the resident's behaviors and medication side effects represents a significant deficiency in the facility's care practices. This failure to adhere to the care plan and physician's orders could result in the resident continuing to exhibit unaddressed behaviors, potentially leading to further harm or distress for the resident and others in the facility.
Broken Recliner Poses Fall Risk
Penalty
Summary
The facility failed to ensure resident furniture was in operable working condition, as evidenced by the continued use of a broken recliner for one of three residents reviewed for falls. On 03/29/24 at 11:32 am, an observation near the nurse's station revealed a recliner with a footrest that was not attached to the mechanism that extended to raise and support the feet. During interviews on 03/29/24 and 04/02/24, the Director of Nursing (DON) confirmed that the footrest on one of the recliners did not lock when in the elevated position and would fall from the elevated position. Staff had been placing a foot stool under the footrest to keep it elevated while a resident sat in the chair. The DON acknowledged that the broken recliner should not have been available for resident use.
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Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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