The Rehabilitation Center Of Albuquerque
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 5900 Forest Hills Drive Ne, Albuquerque, New Mexico 87109
- CMS Provider Number
- 325034
- Inspections on file
- 25
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 46 (2 serious)
Citation history
Health deficiencies cited at The Rehabilitation Center Of Albuquerque during CMS and state inspections, most recent first.
Two residents experienced significant changes in condition without appropriate notification of their POA/emergency contacts or providers. One resident with complex neurologic and vascular diagnoses had multiple documented CIC events, including abnormal vitals with unresponsiveness, seizures, falls with head injury, COVID‑19 infection, swallowing difficulties, and an altercation, yet staff consistently notified only a resident representative who was not the POA, despite clear documentation that the spouse and then the son were to be notified first. Another resident with dementia, chronic respiratory failure, CHF, and hypoglycemia, and designated as full code, developed mouth breathing with gurgling, low O2 saturation requiring increased oxygen, abnormal lung sounds, and decreased responsiveness; the nurse placed this information in a non‑emergent provider log instead of directly contacting a provider or EMS. Later that morning, staff found the resident unresponsive, initiated CPR, and a code blue was called, with the DON and NP confirming that no provider notification had occurred despite the clear CIC.
Two residents experienced deficiencies in care when staff did not follow physician orders for oxygen therapy and STAT diagnostics. One resident with COPD and acute respiratory failure had orders for continuous O2 at 5.5 LPM via nasal cannula, yet was repeatedly observed with the portable O2 device turned off or set below the ordered flow, without a nasal cannula attached, and with an empty portable tank, resulting in low O2 saturations on room air. Staff acknowledged the resident required assistance with O2 therapy, and a CNA reported removing the nasal cannula and not replacing it. Another resident recovering from a right femur fracture developed severe left knee pain with swelling and decreased range of motion; an after-hours provider ordered STAT CBC, CMP, CRP, and a STAT left knee X-ray, but these were not completed because the orders were not documented correctly, causing a delay. The DON confirmed that O2 was not provided as ordered and that STAT labs and imaging were not obtained immediately due to documentation errors.
A resident with an abdominal surgical incision and orders for daily wound care did not receive the prescribed cleansing, packing with antimicrobial dressing, and foam covering for several consecutive days, despite the TAR indicating treatments were completed. When the dressing was finally changed, staff noted increased drainage, redness, and purulent discharge, and a subsequent wound culture was positive for gram negative and gram positive bacteria, including MRSA. The resident reported the dressing had not been changed for several days, and the IP/Unit Manager and DON confirmed that ordered wound care had been missed and not performed as prescribed.
Surveyors found that a treatment cart and a medication cart on the 300 unit were left unlocked and unattended, with access to wound care supplies, scissors, topical creams, multiple oral medications (including Buspirone, Glipizide, Mirtazapine, Venlafaxine, Carbamazepine, Gabapentin, Colace), eye drops, and lancets. An LPN responsible for the carts confirmed they were open and acknowledged they should be locked when not in use, and the DON stated that medication and treatment carts are expected to remain locked and attended to prevent resident access and potential injury.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. For one resident with an abdominal surgical wound, the TAR showed wound care as completed each shift, but progress notes and a communication form later revealed the dressing had not been changed for several days, with increased drainage, redness, purulent discharge, and a culture positive for gram negative and gram positive bacteria. For another resident who experienced a CIC, vital signs taken afterward were not documented in the EHR. The DON confirmed that wound care documentation on the TAR was inaccurate and that the vital signs following the CIC were not entered as required.
A resident was admitted with multiple diagnoses, including a right femur fracture, DM2, cognitive communication loss, and right hip pain, but the baseline care plan developed within 48 hours addressed only skin integrity of the right hip after surgery. The plan omitted other necessary care areas and diagnoses, such as ADLs, fall risk interventions, advanced directives, and diabetic management. A UM confirmed that the baseline care plan was incomplete and did not reflect the minimum healthcare information needed to guide immediate care.
A transport driver violated facility policy by soliciting and accepting $100 from a cognitively intact resident during a bank trip, after repeatedly mentioning personal financial needs. The driver did not repay the money, and the incident was discovered when the resident reported the situation to staff.
A medication error involving a resident with morbid obesity and DM2 was not reported to the State Agency as required by facility policy. The Administrator confirmed the lack of reporting, citing staff turnover, DON absence, and operational challenges as contributing factors.
A resident with diabetes and obesity was given two doses of Mounjaro within 24 hours due to staff administering the wrong injection, confusing it with a similar-looking migraine medication stored in the same refrigerator. The error was compounded by the electronic MAR prompting for the medication and failure to carefully read the label. After the incident, only routine blood sugar checks were performed, with no additional monitoring or documentation of symptom assessment.
A medication cart was found unattended and unlocked in a hallway, with narcotics secured in a locked box but other medications accessible. An RN confirmed leaving the cart unlocked while stepping away, and the interim DON stated that all carts are expected to remain locked to prevent unauthorized access.
A resident's room had a broken wall with a hole that was not reported or repaired by staff. The issue was not documented in the facility's maintenance system, and staff, including a CNA, Maintenance Director, DON, and Administrator, were unaware of the damage until it was observed during a survey. The resident stated the hole had been present since moving in and had not been reported.
A resident with a g-tube did not receive medications according to physician orders and professional standards. The RN administered three medications simultaneously without flushing the tube before or after, as captured on video. The DON confirmed the RN's failure to adhere to the required procedures.
A resident with a history of seizures missed multiple doses of levetiracetam, leading to breakthrough seizures and an emergency hospital transfer. The facility failed to notify the physician about the missed doses, and the medication was available in an alternative form that was not used.
A resident with a history of seizures missed three doses of levetiracetam due to the medication not being available in the cart, leading to breakthrough seizures and emergency medical intervention. The medication was available in the facility's Omnicell but was not utilized.
The facility failed to serve food under sanitary conditions, with multiple residents reporting cold and unappetizing meals. Observations revealed that both hot and cold foods were not maintained at safe temperatures, and the Dietary Manager acknowledged that food carts often sat in the halls for extended periods before delivery.
The facility failed to ensure that meals served to residents were attractive, palatable, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, unappetizing, and sometimes even raw. An observation of a test tray revealed that the green beans were unseasoned and cold, the cheese quesadilla was cold with unmelted cheese, and the pineapple pieces and beverage were warm. The Dietary Manager acknowledged that food carts sitting in the halls for extended periods could contribute to these issues.
The facility failed to ensure accurate insulin use information in MDS assessments for two residents. The assessments indicated insulin administration, but physician's orders and MARs did not support this information. The MDS nurse confirmed the error.
The facility failed to properly store medications in medication carts, resulting in loose medications being found under the medication cards. Observations revealed loose tablets and capsules in the 300 and 400 hall medication carts. The DON confirmed that loose medications are not allowed and staff should check for them daily.
The facility failed to accommodate the dietary preferences of two residents, leading to emotional distress and unmet nutritional needs. One resident did not receive the meals she ordered, while another vegetarian resident was served meat due to miscommunication.
The facility failed to support residents in ADLs by not offering showers according to schedule and not answering call lights in a timely manner. A resident reported not having a shower since admission and not knowing her shower schedule, while another did not receive showers due to staff shortages. Additionally, residents experienced long wait times for call light responses, with one waiting about an hour and another waiting 22 minutes for assistance.
The facility failed to serve food according to the presented menu, leading to residents receiving incorrect meals. One resident received Salisbury steak instead of the posted menu items, and another vegetarian resident was served meat despite their dietary preference being documented.
A resident's call light was found to be non-functional, and despite the resident informing multiple staff members, no action was taken to repair it. The facility's maintenance records showed no work order for the issue, and the Administrator confirmed the oversight.
A resident with multiple respiratory and cardiovascular conditions was observed using oxygen therapy without proper documentation of physician orders and without labeled oxygen tubing and humidifier. Staff confirmed that the equipment should be labeled and orders should be documented upon admission, which was not done in this case.
Failure to Notify POA and Providers of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify resident representatives and providers of significant changes in condition for two residents. For one resident with traumatic hemorrhage of the right cerebrum, carotid artery aneurysm, convulsions, and a cognitive communication deficit, the face sheet and POA documents identified the spouse as POA and first emergency contact, and the son as second emergency contact and secondary POA. Social services documentation and nursing notes showed that this resident explicitly stated that her husband should be the first person notified of any changes in condition and her son the second. Despite this, multiple SBAR forms documented repeated changes in condition, including abnormal vital signs with unresponsiveness, new swallowing issues, a positive COVID test, swallowing difficulties, a fall with head injury, an altercation with another resident, a seizure, and another fall. In each of these events, staff notified only the resident’s daughter‑in‑law, identified as the resident representative, and did not notify the husband or son as emergency contacts/POA. Interviews further confirmed the pattern of non‑notification of the appropriate decision‑makers for this resident. The son reported that the facility did not notify him after any of the resident’s changes in condition and that he learned of these events from the resident representative instead. The husband/POA stated he did not recall being notified by the facility regarding any of the changes in condition and did not know who the facility contacted. The resident representative stated that staff began contacting her instead of the husband and son, sometimes because they did not answer the phone, and acknowledged that this practice bothered the son. The Unit Manager stated that facility nursing staff were required to call the POA and emergency contact for any change in condition and that if a family member onsite was not the POA, staff should still notify the POA. She acknowledged that nursing staff should have contacted the resident’s husband or son regarding the changes in condition, even when the resident representative was present in the facility. For the second resident, who had dementia with behavioral disturbance, chronic respiratory failure with hypoxia, chronic CHF, and hypoglycemia, and who was documented as full code with all interventions, the facility failed to notify a provider when the resident exhibited an acute change in condition. Nursing progress notes documented that in the early morning hours, the resident was mouth breathing with gurgling sounds in the deep throat, had non‑productive coughing, an oxygen saturation of 92% on 3 liters of oxygen, and was uneasily aroused by tactile/verbal stimuli, with abnormal lung sounds including bilateral upper lobe rhonchi and diminished lower lobe sounds. The nurse recorded that the primary care physician was made aware via a non‑emergent in‑house communication log for further evaluation and treatment, and that the oncoming nurse would be informed. Later that morning, the nurse was called to the resident’s room and found the resident unresponsive, with CPR initiated and a code blue performed by EMS, and the resident was pronounced dead. Additional interviews and documentation clarified that the nurse practitioner considered the information placed in the non‑emergent provider logbook inappropriate for that communication channel and stated that staff should have called a facility provider and 911 immediately regarding the resident’s status, rather than using the non‑emergent log. The DON stated that the first time she was made aware of the situation was when the code blue was called and that staff were required to notify a provider for any change in condition; review of the on‑call provider log showed no calls for this resident on the relevant dates. A CNA reported that when she arrived, the resident was not responding or opening her eyes, was coughing with gurgling sounds, and appeared very pale, and that she and another CNA could not obtain a pulse before summoning the nurse and initiating the code blue. The nurse who cared for the resident that morning stated she obtained but did not document vital signs, recalled an oxygen saturation of 88% on 2 liters improved to 92% on 3 liters, noted coughing with inability to expel mucus, and believed the resident was at baseline, so she did not call the on‑call provider and instead wrote in the non‑emergent log. The oncoming nurse stated she was told the resident was not awake or alert enough to receive morning medications, did not see the resident until notified by the CNA that the resident was not breathing, and stated that if a sternal rub was necessary, the nurse performing it should have called the provider. These actions and inactions led surveyors to identify an Immediate Jeopardy related to failure to notify providers and representatives of changes in condition.
Removal Plan
- Provide change in condition (CIC) education to LPN and RN staff, including definition of CIC, appropriate communication to providers, nursing follow-up and documentation responsibilities, consequences of delayed intervention, and importance of timely notification/early recognition and intervention.
- Ensure all nurses on duty since the event receive the CIC education and understand their responsibility (DON/designee verification).
- Conduct an initial review of the non-emergent provider communication log process with the provider and administration team to clarify appropriate acuity of notifications.
- Require that changes of condition be reported directly to the provider; restrict the non-emergent log to non-emergent patient requests or medication refills.
- Update the non-emergent provider communication log form to reflect the revised process.
- Place the agency nurse who documented the progress note on administrative leave pending review of care.
- Conduct an in-person meeting with the agency nurse by two nurse managers to review documentation and provide one-on-one education regarding substandard care.
- Notify the agency of the event and investigation involving the agency nurse.
- Assess and document vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) on every resident in the facility.
- Have nurse managers conduct room-to-room visual inspections to verify proof of life and resident stability.
Failure to Follow Physician Orders for Oxygen Therapy and STAT Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to ensure oxygen therapy was administered according to physician orders for Resident #3. The resident had diagnoses including COPD, acute respiratory failure with hypoxia, and acute respiratory failure, with an order for continuous oxygen via nasal cannula at 5.5 LPM to maintain oxygen saturation above 90%. Observations on multiple days showed the portable oxygen device turned off and set at zero, later turned on but set at only 4 LPM, and the resident in bed without a nasal cannula while the concentrator was running at 4 LPM with no cannula attached. A subsequent observation found the portable oxygen device empty and unable to deliver oxygen, with oxygen saturation documented at 84–86% on room air. Staff interviews confirmed that the oxygen should have been on, set to the ordered flow rate, and that the resident required assistance with oxygen therapy. One CNA reported removing the nasal cannula, finding it on the floor, and not replacing it, leaving no nasal cannula readily available for the resident. Resident #3’s care plan identified risks for respiratory complications, falls, and skin breakdown related to respiratory failure, and a change-in-condition note documented episodes of lethargy, mumbling speech, and oxygen saturations as low as 70–81% on 6 LPM of oxygen, with concern for acute exacerbation of congestive heart failure. Despite these documented respiratory issues and the facility’s oxygen concentrator policy outlining proper setup and use, the resident was repeatedly observed without appropriate oxygen delivery equipment in place or with devices not set to the prescribed flow rate. The DON confirmed that oxygen was not provided continuously via nasal cannula at 5.5 LPM as ordered and stated it was her expectation that oxygen be administered per physician orders. The deficiency also involves the facility’s failure to follow physician orders for STAT laboratory tests and a STAT X-ray for Resident #17. This resident had diagnoses including a right femur fracture, DM2, cognitive communication loss, and right hip pain, and developed severe left knee pain with swelling and decreased range of motion. An after-hours provider ordered STAT CBC, CMP, CRP, and a STAT X-ray of the left knee. Physician orders documented these STAT tests and imaging for severe left knee pain. However, the resident’s daughter reported that when she arrived the next day, she was told the labs and X-ray had not been completed because the orders were not documented correctly. The DON confirmed that the STAT orders for labs and X-ray were not documented correctly, which led to a delay in completing them, and acknowledged that the labs and X-ray should have been obtained immediately per the physician’s orders but were not.
Failure to Provide Ordered Surgical Wound Care Resulting in Infected Abdominal Incision
Penalty
Summary
The facility failed to provide physician-ordered surgical wound care to a resident with an abdominal incision following digestive system surgery. Facility policy dated 09/15/25 required safe and effective wound care, adherence to specific orders for surgical wounds, and daily monitoring of wounds and dressings for complications or decline. The resident was admitted on 09/03/25 with diagnoses including surgical aftercare following digestive system surgery, incisional hernia without obstruction, and unspecified intestinal obstruction. Physician orders dated 12/17/25 directed that the abdominal wound be cleansed with wound cleanser, patted dry, packed with optical AG rope, and covered with a foam dressing every day shift from 12/17/25 through 12/23/25. The Treatment Administration Record for 12/17/25 through 12/23/25 showed the wound care as completed every shift as ordered. However, nursing progress notes dated 12/22/25 documented that the midline abdominal surgical wound dressing was changed that day, and that the last dressing change had actually occurred on 12/18/25, indicating that ordered wound care had not been completed between 12/18/25 and 12/22/25. At that time, increased drainage with thick brown serosanguineous fluid and increased redness around the wound were observed, and the wound nurse was notified of the worsening appearance. A communication form entry dated 12/22/25 recorded a reddened abdominal incision with purulent drainage, with the resident reporting the dressing had not been changed since 12/17/25. A wound culture subsequently tested positive for gram negative and gram positive bacteria, and the resident’s daughter was notified of the missed treatments and positive culture. In interviews, the daughter confirmed being told that the bandage had not been changed for several days, the Infection Preventionist/Unit Manager acknowledged that scheduled wound care was missed from 12/18/25 through 12/22/25 and that the incision became inflamed, reddened, and MRSA-positive, and the DON confirmed that the wound care was not completed per physician orders.
Unsecured Medication and Treatment Carts on 300 Unit
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to properly secure medication and treatment carts on the 300 unit. On 03/17/26 at 2:39 PM, the wound care treatment cart was observed unlocked and open, containing wound care supplies, tweezers, topical creams, and scissors, with no nursing staff present in the area. Later that same day at 3:10 PM, the medication cart on the 300 unit was also observed unlocked and open, containing multiple medications including Buspirone, Glipizide, Mirtazapine, Venlafaxine, Carbamazepine, Gabapentin, Colace, eye drops, and lancets, again with no nursing staff present nearby. During an interview on 03/17/26, an LPN acknowledged that she was responsible for both the treatment and medication carts and confirmed they were unlocked and open. She stated that the carts should be locked when not in use and that medication carts should never be left open because a resident could ingest medications not prescribed to them, resulting in illness. On 03/18/26, the DON stated that staff should never leave a medication or treatment cart unlocked and unattended, and that her expectation is that all such carts are locked when not in use. She further stated that if a medication or treatment cart were left unlocked, residents could access the contents and sustain injury.
Incomplete and Inaccurate Medical Record Documentation for Wound Care and Change in Condition
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for two residents. For one resident with a midline abdominal surgical wound, the Treatment Administration Record (TAR) for a specified period showed that surgical wound care was documented as completed every shift per physician orders. However, a nursing progress note later documented that on one date the dressing was changed and the old dressing was still dated several days earlier, indicating that wound care had not been performed as ordered during that interval. The same note described increased drainage with thick brown serosanguineous fluid and increased redness around the surgical site, and the wound nurse was notified of the worsening appearance. A communication form entry further documented that the abdominal incision was reddened with purulent drainage, that the resident reported the dressing had not been changed for several days, and that a wound culture was positive for gram negative and gram positive bacteria, confirming an infected surgical wound. The DON stated that it was her expectation that wound care be accurately documented and performed according to physician orders and confirmed that the TAR documentation showing wound care as completed on the specified dates was not accurate. For another resident who experienced a change in condition, the Electronic Health Record (EHR) did not contain documentation of vital signs taken in the early morning following that change. Record review showed that vital signs obtained at a specific time were not entered into the EHR after the change in condition occurred. In an interview, the DON confirmed that the resident’s vital signs were not documented in the EHR after the change in condition and acknowledged that they should have been documented. These findings show that the facility failed to ensure that medical records, including treatment documentation and vital signs following a change in condition, were complete and accurate for both residents.
Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop and implement an adequate baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed the resident was admitted with multiple diagnoses, including a right femur fracture, type II diabetes mellitus, cognitive communication loss, and right hip pain. The baseline care plan, dated the day after admission, addressed only skin integrity of the right hip after surgery and did not include any other care areas or diagnoses. During an interview, the Unit Manager stated that a complete baseline care plan should include ADLs, fall risk interventions, wounds and skin care, advanced directives, and specialized care such as diabetic management. The Unit Manager confirmed that the resident’s baseline care plan was not complete and did not meet these expectations. The incomplete and inaccurate baseline care plan resulted in the absence of documented interventions for several of the resident’s admitting conditions.
Misappropriation of Resident Property by Transport Driver
Penalty
Summary
A deficiency occurred when a transport driver took money from a resident, violating the facility's Code of Conduct, which prohibits staff from asking for or accepting tips, gifts, loans, or monetary transactions from residents or their family members. The resident, who was cognitively intact according to a recent assessment, reported that during a trip to the bank, the driver repeatedly mentioned needing money and recounted stories about his family, which led the resident to feel inclined to loan the driver $100. The driver assured the resident that he would repay the money with his next paycheck, but after about a month without repayment or contact, the resident attempted to reach the driver through facility staff. The incident came to light when the resident informed the transport clerk about the loan and provided the driver's name and description. Upon investigation, the driver admitted to taking the money but claimed it was given as a tip. The facility's records confirm that the driver accompanied the resident into the bank and engaged in conversations that influenced the resident to provide the money. The facility's policy clearly states zero tolerance for any form of misappropriation or exploitation of resident property, and this event constituted a direct violation of that policy.
Failure to Report Medication Error to State Agency
Penalty
Summary
The facility failed to report a medication error involving a resident with diagnoses of morbid obesity and Type 2 diabetes mellitus. According to the facility's Abuse Prohibition Policy, all allegations of abuse, neglect, or incidents resulting in serious bodily injury must be reported immediately or within specified timeframes. Despite this policy, the medication error was not reported to the State Agency as required. Record review showed the resident had active physician orders for Mounjaro (tirzepatide) and Emgality for diabetes and migraine prophylaxis, respectively. During an interview, the Administrator confirmed that the medication error was not reported and attributed the failure to high staff turnover, the Director of Nursing being on leave, the training of a new DON, and ongoing staffing instability at the time of the incident.
Significant Medication Error: Duplicate Dose of Mounjaro Administered
Penalty
Summary
Staff failed to prevent a significant medication error when a resident with morbid obesity and Type 2 diabetes mellitus received two doses of Mounjaro (tirzepatide) 12.5 mg within 24 hours, contrary to the physician's order for once-weekly administration. The error occurred when staff administered Mounjaro instead of the resident's scheduled Emgality injection for migraine prophylaxis. The medications were stored together in the same refrigerator and appeared similar, contributing to the confusion. The electronic medication administration record (MAR) continued to prompt for Mounjaro administration, which also contributed to the error. The nurse who administered the medication did not read the medication label carefully, leading to the administration of the wrong drug. Following the error, the nurse notified the resident, nurse practitioner, guardian, and charge nurse, and Poison Control was contacted. The nurse practitioner ordered enhanced monitoring, including holding the resident's oral antidiabetic medications and increasing blood glucose checks. However, documentation showed that staff only continued routine blood sugar checks and did not increase monitoring or document reassessment for side effects or symptoms beyond the resident's baseline schedule. There was no nursing narrative assessing for symptoms or evidence of monitoring for adverse effects as recommended.
Unattended and Unlocked Medication Cart Found on Hallway
Penalty
Summary
A medication cart was observed on the 200 Hall with the top drawer unlocked and unattended, allowing potential unauthorized access to medications. No staff were present in the immediate area at the time of observation. Facility policy requires all medications to be secured at all times, with medication carts locked when not in the direct possession of licensed staff, and controlled substances stored in a separately locked compartment. The unattended cart contained narcotics in a locked box, while other resident medications were accessible in the unlocked drawers. During an interview, a registered nurse confirmed she had left the cart unlocked while stepping into a resident's room, acknowledging that this could allow a resident to access medications not prescribed to them. The interim Director of Nursing also stated that her expectation is for all medication carts to remain locked at all times to prevent unauthorized access. The incident involved one medication cart and did not specify any particular resident's medical history or condition at the time.
Failure to Report and Repair Broken Wall in Resident Room
Penalty
Summary
Staff failed to report or repair a broken wall in a resident's room, resulting in an environment that was not safe, functional, sanitary, or comfortable. The broken wall, which included a hole, was observed during a facility visit. The resident stated that the hole had been present since moving into the room and had not been reported to staff. Review of facility work orders confirmed that the issue had not been documented or addressed by staff. Interviews with facility staff, including a CNA, the Maintenance Director, the DON, and the Administrator, revealed that none were aware of the broken wall prior to the survey. Staff indicated that maintenance issues are expected to be reported through the facility's Equipment Lifecycle System (TELS), but this process was not followed in this instance. The Maintenance Director noted the damage was likely caused by water and acknowledged the potential for mold and pest entry. The Administrator stated that quality of life rounds had not yet included the affected room and that maintenance rounds alone were insufficient to identify all issues.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to a physician's order and professional standards of practice for medication administration for a resident with a gastronomy tube (g-tube). The resident, diagnosed with traumatic brain injury, cerebrovascular accident, and transient ischemic attack, had specific physician orders to flush the g-tube with water before and after each medication pass and between each medication administered via the g-tube. However, on a specific date, a registered nurse (RN) administered three medications simultaneously via a 50 mL syringe into the resident's g-tube without flushing the tube before or after the administration, contrary to the physician's orders. The incident was captured on video by the resident's Power of Attorney, who had installed a camera in the resident's room. The Medication Administration Record confirmed that the RN administered dantrolene, donepezil, and Tylenol at the same time. A peer-reviewed article from the National Institute of Health emphasized the importance of administering each medication separately and flushing the tube with water before and after each medication. During an interview, the Director of Nursing acknowledged that the RN did not follow the required procedures for medication administration via the g-tube.
Failure to Notify Physician of Missed Seizure Medications
Penalty
Summary
The facility failed to notify the physician for a resident when they did not immediately inform the physician of the resident's missed seizure medications. The resident, who had a history of traumatic brain injury, seizures, and other severe conditions, missed doses of levetiracetam on multiple occasions. This resulted in the resident experiencing breakthrough seizures and low blood oxygen saturation, leading to an emergency hospital transfer. The resident's medication administration record showed that the evening dose of levetiracetam was not administered on one day, and both morning and evening doses were missed the following day. Despite the medication being available in tablet form in the facility's Omnicell, staff did not administer it or notify the physician about the missed doses. The resident's condition deteriorated, and they were transferred to the hospital after experiencing multiple seizures. The facility's records did not contain documentation explaining why the medication was not administered or why the physician was not notified. The Director of Nursing confirmed that the medication was not available in the prescribed liquid form but was available in tablet form, which could have been used. The failure to notify the physician and administer the medication as ordered led to a delay in treatment for the resident.
Failure to Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to administer levetiracetam, an anti-seizure medication, to a resident on three occasions as per the physician's order. The resident, who had a history of traumatic brain injury, seizures, and a persistent vegetative state, missed doses on the evening of 12/14/2023 and both morning and evening of 12/15/2023. This led to the resident experiencing adverse side effects, including breakthrough seizures, which required emergency medical intervention. The medication administration record (MAR) confirmed that the doses were missed, and the electronic medical record (EMR) indicated that the resident's condition deteriorated, with unstable vitals and seizures occurring intermittently. The facility's investigation revealed that the medication was not available in the medication cart, although it was accessible in the facility's automated medication storage system (Omnicell) in tablet form, which could have been crushed and administered via the resident's G-Tube. Interviews with the Director of Nursing (DON) and staff statements corroborated that the medication was not administered due to its unavailability in the cart. The DON acknowledged that the medication was available in the Omnicell and could have been used as an alternative. The facility initiated an investigation and corrective actions following the incident, but the deficiency resulted in significant harm to the resident due to the missed doses of the critical medication.
Failure to Serve Food Under Sanitary Conditions
Penalty
Summary
The facility failed to serve food under sanitary conditions in accordance with professional standards of food service safety. Multiple residents reported that their food was often served cold and unappetizing. Specific instances included a resident stating they were served raw chicken on several occasions and another resident mentioning that breakfast was cold when delivered to their room. Observations and interviews revealed that the internal temperatures of both hot and cold foods were not maintained at safe levels, with hot foods being served below 135°F and cold foods above 41°F. For example, a cheese quesadilla measured 101.9°F, seasoned potato wedges at 96.0°F, pineapple tidbits at 60.5°F, and a cup of lemonade/juice at 49.8°F. Additionally, egg salad sandwiches and Italian sub sandwiches were also found to be above the recommended temperature for cold foods. The Dietary Manager (DM) acknowledged the temperature discrepancies and noted that the food cart often sat in the halls for extended periods before staff delivered meals to residents' rooms, which could contribute to the temperature issues. The DM verified that hot foods should be served hot and cold foods should be served cold unless otherwise requested by the resident. The failure to monitor and maintain appropriate food temperatures is likely to result in foodborne illnesses and could affect all 115 residents in the facility.
Failure to Ensure Meals are Palatable and at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents were attractive, palatable, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, unappetizing, and sometimes even raw. Specific instances included a resident stating that the food was not always hot and arrived cold to her room, another resident mentioning that the food was regularly cold and unappetizing, and another resident stating that the food was often unidentifiable and tasted awful. Additionally, one resident reported being served raw chicken on several occasions, and another resident frequently requested alternative meals due to the poor quality of the regular meals, although the alternatives were also sometimes unsatisfactory. An observation of a test tray revealed that the green beans were unseasoned and cold, the cheese quesadilla was cold with unmelted cheese, and the pineapple pieces and beverage were warm. The Dietary Manager (DM) acknowledged that residents had complained about the food carts sitting in the halls for extended periods before meals were delivered to their rooms, which could contribute to the complaints of cold food. This deficiency in meal service reduces residents' ability to enjoy their meals and may negatively impact their quality of life. The report highlights the facility's failure to maintain meal quality standards, as evidenced by the residents' consistent complaints and the observed condition of the test tray meal.
Inaccurate Insulin Use Information in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments included accurate insulin use information for two residents. For one resident, the quarterly MDS assessment indicated that the resident received seven insulin injections during the seven-day look-back period. However, a review of the resident's physician's order summary and Medication Administration Record (MAR) for the same period showed no orders or administration of insulin. Similarly, for another resident, the quarterly MDS assessment also indicated seven insulin injections during the look-back period, but the physician's orders and MAR did not support this information. During an interview, the MDS nurse confirmed that neither resident had an order for the administration of insulin during the look-back period and acknowledged that staff should not have indicated insulin administration on the MDS assessments. This discrepancy in the MDS assessments could likely result in residents not receiving the most optimal and personalized care required to meet their highest practicable outcomes.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to properly store medications in medication carts, resulting in loose medications being found under the medication cards. Specifically, during an observation of the 400 hall medication cart, a loose round, white tablet was found under the medication cards. Similarly, during an observation of the 300 hall medication cart, multiple loose medications were found, including one white oval tablet, two pink oval tablets, one liquid capsule, and two white circular tablets. The Director of Nursing (DON) confirmed that loose medications are not allowed to be stored in the medication carts and that staff should check for loose medications daily.
Failure to Accommodate Dietary Preferences and Needs
Penalty
Summary
The facility failed to accommodate the food preferences and dietary needs of two residents, leading to frustration and emotional distress. Resident #36 consistently did not receive the meals she ordered, despite submitting her order sheet daily. On one occasion, she was served chicken fried steak instead of the Salisbury steak she had requested, causing her to become visibly upset and cry. The Dietary Manager confirmed that the kitchen had run out of Salisbury steaks but was unsure why some residents still received them. This indicates a lack of proper meal planning and communication within the dietary department. Resident #49, who follows a vegetarian diet, was served a meal containing meat, contrary to her dietary preferences. The Dietary Manager was unaware of her vegetarian diet and stated that the resident usually ordered a cheese quesadilla. The failure to provide a vegetarian meal was attributed to a miscommunication between the CNA and the cook. This oversight highlights a significant gap in the facility's ability to adhere to residents' dietary preferences and ensure their nutritional needs are met.
Failure to Provide Scheduled Showers and Timely Call Light Response
Penalty
Summary
The facility failed to support residents in activities of daily living (ADLs) by not offering showers according to a pre-planned and agreed-upon schedule and not answering call lights in a timely manner. Resident #309, who was cognitively intact and required substantial assistance with ADLs, reported not having a shower since admission and not knowing her shower schedule. The Director of Nursing (DON) confirmed that Resident #309's shower schedule was every Thursday and Sunday, but records showed inconsistencies in offering showers. Similarly, Resident #2, who also required assistance with ADLs, did not receive showers as scheduled due to staff shortages, as confirmed by the DON. Records indicated that Resident #2 was not offered showers on multiple scheduled days in March 2024. The facility also failed to respond to call lights in a timely manner. Resident #309, who required substantial assistance for toileting and transfers, reported that staff did not come to assist her after pressing her call light, leading her to go to the bathroom on her own after waiting for about an hour. Another resident, #73, was observed waiting 22 minutes for assistance after activating the call light. The DON stated that staff should answer call lights within 10 to 15 minutes, acknowledging that 15 minutes would be too long to wait for care. These deficiencies are likely to negatively impact resident safety, comfort, and timely incontinence care.
Failure to Follow Menu and Dietary Preferences
Penalty
Summary
The facility failed to serve food according to the presented menu, which is a repeat deficiency. During an interview, a resident stated there was not much variety, and the menu was not followed. On a specific date, the posted lunch menu included country fried steak with mushroom gravy or fish tacos, along with other side items. However, during a meal observation, a resident was served Salisbury steak, mashed potatoes with brown gravy, and a small bowl of salad, which did not match the posted menu. The resident's meal ticket also indicated Salisbury steak, confirming the discrepancy between the menu and the served meal. Another resident, who is vegetarian, was served Salisbury steak, mashed potatoes with brown gravy, and a small bowl of salad, despite their meal ticket indicating a cheese quesadilla, seasoned green beans, and pineapple tidbits. The resident's dietary preference for a vegetarian diet was documented in their records. The Dietary Manager acknowledged that sometimes substitutions are made due to out-of-stock items but was unsure why the incorrect meals were served. The Dietary Manager also stated that the Certified Nursing Assistant did not specify the correct tray for the vegetarian resident.
Non-Functional Call Light
Penalty
Summary
The facility failed to ensure a resident's call light was functioning as intended. During an observation, the resident was found with a call light button attached to her bedside commode, which did not work when pressed. The resident reported that the call light had been non-functional for several days and that she had informed multiple staff members, but no action had been taken. A review of the facility's maintenance work orders revealed no record of an open or resolved work order for the call light. The Administrator confirmed that the call light was in need of repair and acknowledged that no work order had been entered.
Failure to Properly Document and Label Oxygen Therapy
Penalty
Summary
The facility failed to meet professional standards of care for a resident requiring oxygen therapy. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia following a stroke, asthma, chronic diastolic heart failure, obstructive sleep apnea, and other pulmonary embolism, was observed using oxygen through a nasal cannula. However, the oxygen tubing and humidifier were not labeled with the date of the last equipment change. Additionally, the resident's medical record did not contain physician orders for oxygen therapy or for changing the oxygen tubing and humidifier. During interviews, staff confirmed that the oxygen equipment should be labeled with the date of the last change and that the resident's medical record should include physician orders for oxygen therapy and equipment changes. The Director of Nursing acknowledged that the resident was admitted on oxygen therapy without the necessary physician orders in her chart and that the facility's policy was to enter these orders at the time of admission. The failure to follow these protocols was identified as a deficiency in the facility's care standards.
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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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