The Suites Rio Vista
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Rancho, New Mexico.
- Location
- 2410 19th Street Se, Rio Rancho, New Mexico 87124
- CMS Provider Number
- 325127
- Inspections on file
- 35
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at The Suites Rio Vista during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported that a CNA providing personal care intentionally struck her with a small pillow and then a flowered blanket, continuing even after she told the CNA to stop and also hitting items on her wall. The resident filed a grievance describing this abusive behavior. Record review confirmed the grievance details, and the facility’s investigation substantiated that the physical abuse occurred, with leadership acknowledging that the CNA’s actions were inappropriate.
A resident with impaired physical functioning and a left AKA, care-planned for two-person substantial/max assist and Hoyer lift transfers, was being repositioned by one CNA while the bed was left in the highest position and the resident was instructed to hold the bedrails, leading to a witnessed fall from the bed. After the fall, the resident repeatedly reported severe back and knee pain, with documented edema, bruising, and pain behaviors, while initial imaging was read as negative and the resident was not immediately sent to the ER. Persistent severe pain led to repeat imaging that revealed a right femur fracture, and subsequent hospital evaluation also identified lumbar compression fractures, confirming that the unsafe bed position and inadequate supervision contributed to a serious injury event.
The facility failed to ensure that non-clinical staff providing feeding assistance to a resident with dysphagia had specialized training and competency validation, while also not completing a physician-ordered swallowing evaluation. Another resident scheduled for shoulder surgery did not receive or have documented pre-op NPO instructions or education, resulting in the procedure not occurring as planned. A third resident who sustained a fall and reported ongoing pain was not transferred promptly to the hospital; instead, initial imaging was followed days later by a second x-ray that revealed a femur fracture, after which the resident was finally sent to the ED.
Two residents had inaccurate MDS assessments related to hearing, O2 use, and functional status. One resident with complex respiratory and neurologic conditions was repeatedly observed responding "huh" during interactions, while an LPN described him as hard of hearing, yet his MDS coded no hearing difficulty and documented speech/audiology services not supported by physician orders or notes; his history of fluctuating O2 use and nasal cannula support also was not reflected in the MDS. Another resident with Parkinson’s disease and dysphagia was consistently documented in nursing notes and by staff as bedbound and dependent in all ADLs, but her MDS Section GG continued to code wheelchair use as the usual mobility device, and no significant change MDS was completed despite a documented functional decline to bedbound status.
The facility failed to accurately complete PASARR Level I screenings for two residents with documented mental health conditions. One resident had anxiety disorder and major depressive disorder, was receiving antianxiety and antidepressant medications, and had a care plan addressing depressive symptoms, yet the PASARR documented no mental illness. Another resident had generalized anxiety disorder and major depressive disorder, multiple readmissions, and a care plan including hydroxyzine for anxiety and monitoring for side effects, but two PASARR screenings failed to list any mental illness. The AD confirmed that these diagnoses were omitted from the PASARRs and acknowledged that missing diagnoses make the PASARR process inaccurate and may prevent residents from receiving all required services or appropriate placement.
Surveyors found that the facility failed to maintain comprehensive, person-centered care plans for two residents. One resident, at risk for PUs and later found to have a sacral wound with physician-ordered treatment, did not have wound care interventions added to the care plan for approximately two months after the wound was identified. Another resident with documented respiratory failure and pulmonary edema had a care plan that omitted O2 use as an intervention and lacked any problem, goal, or interventions related to hearing limitations or hearing aids. The DON confirmed these omissions and stated that hearing difficulties and O2 use should have been included in the residents’ care plans.
Surveyors found that the facility failed to meet professional standards by not completing required AIMS assessments for two residents on antipsychotic medications, not providing ordered feeding assistance to a resident care planned for substantial help with eating, and allowing an LPN to administer heparin using an insulin syringe instead of appropriate injection equipment. The DON and ADON confirmed that AIMS assessments should have been done for residents on antipsychotics, that staff should have been present to assist the resident during meals per the care plan and physician order, and that insulin syringes are intended only for insulin and should not have been used for heparin.
Surveyors found that medications for a resident, including Pravastatin, Methocarbamol, and Buspirone, were left unattended on top of a medication cart without staff present, and both the ADON and a CMA acknowledged that these medications should not have been left unsecured. In a separate observation of medication storage rooms, lancets had been removed from their original packaging and stored loosely in a large, unlabeled bin without expiration dates, and the DON confirmed that this was how new lancet shipments were routinely handled and that this practice was unacceptable.
A resident’s advance directive information was not kept consistent across the EHR and related documents. The face sheet and care plan both identified the resident as Full Code, while the NM MOST form listed the resident as DNR. During interview, the DON confirmed that the correct code status was Full Code and that the NM MOST form was inaccurate, resulting in conflicting documentation of the resident’s end-of-life wishes.
The facility failed to complete a Significant Change in Status MDS within the required timeframe for a resident who experienced a witnessed fall followed by severe pain, later confirmed as a right femur fracture and additional spinal compression fractures requiring ORIF and use of a knee immobilizer. Despite documented decline in function, mobility, and independence and the need for a higher level of care, the Significant Change MDS was not completed until about one and a half months after the injury, and the DON acknowledged that a change in condition MDS should have been completed much sooner.
A resident was discharged to the hospital, but the facility failed to complete and submit the required discharge MDS within the mandated 14-day timeframe. Review of the EHR showed the discharge MDS was not submitted and accepted until more than four months after discharge. In an interview, the MDSC confirmed the assessment was late and acknowledged it should have been submitted within the required period.
A resident’s documented code status was inconsistent across records when staff failed to update the care plan to reflect the resident’s DNR status. The face sheet and NM MOST form identified the resident as DNR, but the care plan listed the resident as Full Code. During interview, the DON acknowledged the advance directive care plan was inaccurate and should have been revised to match the NM MOST.
A resident admitted with a deep incisional surgical site infection had hospital discharge orders for a wound VAC to remain on continuously at 125 mmHg for six days, but these orders were altered by an ADON without provider authorization. A subsequent order directed intermittent wound VAC dressing changes and three-times-weekly wound care instead of continuous therapy, and documentation showed the ordered wound care was performed only once. The wound VAC was later found set at 190 mmHg with no suction at the wound site and drainage under the dressing, and the wound had dehisced, prompting the resident to contact the surgeon directly while the DON observed the wound’s decline and the NP reported she had not been informed of the worsening condition.
Two residents did not receive respiratory care in accordance with professional standards when one resident with a history of respiratory failure and pulmonary edema had inconsistent documentation and implementation of O2 therapy, including lack of active O2 orders, absence of O2 use during observation, and no O2 intervention in the care plan or MDS, while an oxygen concentrator sat unused at the bedside. Another resident with Parkinson’s disease, dysphagia, and weakness had a PRN order for O2 at 1–4 LPM via nasal cannula, yet surveyors twice observed that no O2 equipment was present in the room, despite the DON’s expectation that ordered O2 and equipment be available.
A resident with Parkinson’s disease, dysphagia, GERD, and malnutrition had physician orders for dental evaluation and treatment and a care plan indicating dependence on staff for oral hygiene, with MDS assessments showing a need for supervision or touching assistance. However, the EHR contained no documentation of any dental evaluation or treatment since admission, and a progress note listed all oral health areas as “Not Assessed.” On observation, the resident had broken teeth with visible plaque and discoloration and reported ongoing dental pain known to staff. The DON stated the resident had not received dental services because mobile dental services had not been secured and the resident was bedbound and unable to transfer for outside appointments, and acknowledged the resident should have been evaluated and/or treated.
A resident's code status was inconsistently documented, with the face sheet missing the information, hospital and NM MOST forms indicating DNR, and the care plan listing Full Code. A family member was told by a nurse that the resident was Full Code, despite prior DNR documentation. The DON confirmed the inconsistency and stated the facility presumes Full Code if not documented.
Staff left an electrical junction box and fire alarm control panel unsecured and accessible, with exposed wires in common areas. Electrical cords for a power wheelchair were left stretched across a hallway floor, creating a tripping hazard. In a resident's room, a large kitchen knife and an open can of WD-40 were found accessible. Facility policy required these hazards to be secured or removed to ensure resident safety, but these actions were not taken.
A resident with paraplegia, depression, and PTSD attempted to leave the facility at night and was physically restrained by a nurse, who swatted the resident's hands to prevent exit. The incident was confirmed by security footage and led the resident to report feeling scared and unsafe.
A facility failed to accurately investigate and document an abuse allegation after a resident called police when a nurse tried to prevent him from leaving. The follow-up report submitted to the State Agency included unverified information about the resident's suspected drug use and emergency room visits, which was not supported by the medical record. The administrator later admitted to confusing the resident with another, resulting in an inaccurate report.
A resident with a history of depression and documented behavioral issues, including suicidal and homicidal ideations, was not accurately assessed in the MDS, which failed to reflect these concerns. Multiple records and staff interviews confirmed ongoing behavioral and mental health issues, but the federally mandated assessment did not capture this information.
A treatment cart containing wound care supplies, including mineral oil, tweezers, and scissors, was observed left unlocked and unattended on the 600 Unit. Multiple staff members, including an RN, a CMT, and the DON, confirmed that the cart should be locked when not in use, but this protocol was not followed on more than one occasion.
The facility did not report allegations of possible neglect or abuse involving three residents to the State Agency. The Administrator was aware of the incidents, which included a CNA and a resident with no sexual contact indicated, and medication errors involving two other residents. The Administrator did not believe these incidents warranted reporting, despite usually over-reporting to the state agency.
The facility failed to investigate and report allegations of abuse and mistreatment involving three residents. One resident experienced a medication error leading to choking, another was involved in an alleged sexual misconduct incident with a CNA, and a third resident reported a medication error. None of these incidents were documented in the facility's reportable incidents or reported to the state agency.
The facility failed to maintain sanitary food storage practices, with unlabeled and undated food items found in both the kitchen and unit nourishment rooms. Items meant to be frozen were improperly stored in the refrigerator, and the Dietary Manager confirmed these deficiencies, acknowledging the need for proper labeling and storage.
The facility failed to protect residents' PHI by leaving vital sign sheets and a neuro check form exposed at nurses' stations and on medication carts, accessible to unauthorized individuals. Staff confirmed these breaches of protocol, highlighting a deficiency in safeguarding sensitive information.
The facility failed to maintain a clean and homelike environment by leaving breakfast meal trays with trash and old food in the rooms of three residents. This was observed during a survey, and the residents expressed frustration over the situation. A registered nurse and the Director of Nursing confirmed that the trays should have been collected sooner by the CNAs and nursing staff.
The facility failed to create comprehensive care plans for two residents, neglecting their activity preferences. One resident, with conditions like metabolic encephalopathy and depression, had preferences for religious services and outdoor activities, which were not included in their care plan. Another resident, with a history of stroke and vascular dementia, preferred family interaction and group activities, but these were also omitted from their care plan. The Activities Director admitted to not updating care plans despite completing assessments.
The facility failed to update care plans for a resident requiring extensive ADL assistance and two residents receiving hospice services. The care plan for a resident with significant ADL needs did not specify the required staff assistance, confirmed by interviews with staff. Additionally, hospice services were not included in the care plans for two residents, despite their admission to hospice, as confirmed by hospice staff and the DON.
The facility failed to meet professional standards for two residents: one with diabetes was allowed to self-administer insulin without proper assessment or physician orders, and another with COVID-19 did not receive antiviral medication on time due to unavailability and lack of provider notification. These oversights were confirmed by staff and management.
The facility did not ensure physician responses to pharmacist recommendations during monthly drug regimen reviews for several residents. Recommendations for medication adjustments and updates were signed off by the former DON or an LPN without physician input, potentially leaving medication regimens unevaluated. The ADON confirmed the lack of proper physician review, which could lead to improper medication management.
A facility failed to maintain a medication error rate below 5%, with a 14.71% error rate observed. A CMA administered morning medications to a resident outside the prescribed time, citing a delay to obtain the resident's blood pressure. The facility's policy allows a two-hour window for administration, but the delay resulted in a deviation from the schedule, highlighting a deficiency.
A resident with left-sided hemiplegia and impaired gait did not have her call light pad within reach, as required by her care plan. During an observation, the call light pad was found on the opposite side of the bed, out of reach. The resident stated she could not reach it, and a CNA confirmed it should have been placed closer. The DON also acknowledged that the call light pad should always be within reach.
A facility failed to ensure the accuracy of a resident's PASRR assessment, which is essential to prevent inappropriate nursing home placement. The resident's PASRR Level 1 indicated a need for a Level 2 referral before admission, but no documentation of this referral was found. Interviews with the Social Services Director and Administrator confirmed the oversight, acknowledging the PASRR Level 1 was incorrect and should have been verified before admission.
A resident in a long-term care facility did not receive timely access to vision services, as an optometry appointment for eyeglasses was delayed. Despite a physician order, the appointment was not scheduled until a month later, causing the resident distress due to the lack of necessary vision correction. Both the Social Services Director and the DON confirmed the delay in scheduling.
A facility failed to secure an electric cord, creating a tripping hazard in a resident's room. A CNA tripped over the cord while repositioning the resident, although she did not fall, she bumped into the bed. An LPN confirmed the cord was unsecured and posed a risk.
A facility failed to provide appropriate respiratory care for a resident with COPD, who required the use of CPAP/Bi-PAP equipment. The resident's family managed the equipment setup, and there were no provider orders for its use or maintenance until two weeks after admission. The DON confirmed the absence of orders, indicating a deficiency in the facility's care responsibilities.
The facility failed to ensure medication carts were locked when unattended. A nurse left the 300 wing cart unlocked, and another nurse left the 500 wing cart unlocked with medications and lancets on top. Both nurses and the ADON confirmed that carts should not be left unlocked.
A resident with dental pain and recurrent gingivitis did not receive timely dental care due to the cancellation of the in-house dentist's contract. Despite a physician's order for a dental referral, the resident was not seen by a dentist, leading to ongoing pain and unmet dental needs. The Social Services Director and DON confirmed the oversight.
The facility failed to maintain proper infection prevention measures for two residents. A resident's nebulizer mask was not stored in a bag, as it was found lying on a nightstand. The resident stated they were never given a bag, and staff confirmed the mask should be stored properly. Additionally, a CMA used her bare fingers to pour medications for another resident, which is not a proper infection control practice. The CMA admitted to this action, and the DON confirmed that staff should not use bare fingers to handle medications.
A resident admitted for skilled care services due to severe cervical stenosis had incomplete medical records, lacking daily notations of admission, condition, and care provided. Despite multiple diagnoses, including Type 2 Diabetes and spinal stenosis, the records were inadequate, with no daily skilled care notes until the third day. On discharge day, the resident was drowsy with low blood sugar, leading to a hospital transfer. The DON confirmed the records were insufficient in detailing daily care and condition changes.
A resident with quadriplegia and a traumatic brain injury fell when a shower gurney collapsed due to a missing pin. The incident occurred during a transfer to the shower room, causing the resident to slip to the ground. The gurney's head fell because the supporting pin was missing, as confirmed by staff interviews and the resident's account. The facility acknowledged the equipment failure.
Failure to Protect a Resident From Physical Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by staff during the provision of personal care. The resident, a long-term resident with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, reported that on a specific date a CNA providing direct care in her room intentionally struck her with her small pillow and then with a flowered blanket. According to the resident’s grievance and subsequent interview, she told the CNA to stop, but the CNA continued by hitting her with the blanket and also striking personal items hanging on her wall, attempting to knock her belongings off. The resident stated she felt upset by the incident and filed a grievance with the facility. Record review confirmed the resident’s long-term status in the facility and documented her grievance alleging that the CNA slapped her with a pillow and blanket. The facility’s investigative report, as referenced in the record review, substantiated that the abuse occurred. Interviews with the DON and the Administrator confirmed their awareness of the grievance and that the involved CNA was an agency staff member. The DON stated that the CNA should not have struck the resident with the pillow and blanket, and the Administrator stated that, although there were no witnesses, he believed the resident’s account and noted that she did not have cognitive deficits and was a strong self-advocate. The core deficiency is that facility staff, specifically an agency CNA, engaged in intentional physical contact with the resident using a pillow and blanket in a manner characterized as rude and abusive while providing care.
Failure to Maintain Safe Bed Position and Adequate Supervision Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents when a resident’s bed was left in the highest position during care, resulting in a fall. The resident had an admission date of 01/23/23 and a care plan that identified impaired physical functioning and a risk for falls related to a left above-knee amputation, with interventions including two-person substantial/max assist for ADLs and use of a Hoyer lift with two-person assist for transfers. During care on 10/08/25, a CNA provided care alone, asked the resident to hold onto the bedrails during repositioning while the bed was in the highest position, and the resident fell to the floor. Following the fall, nursing progress notes documented that the resident reported pain to the lower back, right leg/hip, and left arm, and the practitioner was notified with orders for topical analgesic, Oxycodone, labs, and X‑rays. Over the next several days, multiple notes described the resident’s ongoing and severe pain, including 10/10 back and knee pain, moaning in pain during care, increased right knee pain, right foot edema and bruising, and a large bruise on the left hand. Physical therapy notes indicated the resident reported 10/10 back pain, aching pain to the right side of the head, and later right leg pain with tenderness from the right hip to the toes, with a noted decline in mobility and increased fall risk. Provider notes documented inconsistent pain reporting, screaming, nonspecific pain, and the use of pain medications including a muscle relaxer and low-dose Oxycodone. The DON stated that the resident was not sent to the ER immediately because the resident did not report a head injury, although back pain was reported, and that initial X‑rays of the lower back and right distal femur were read as negative. Due to persistent knee pain, a second X‑ray was ordered and completed, and results received on 10/15/25 showed a right femur fracture, after which the resident was transferred to the hospital. Hospital records confirmed a right distal femur fracture requiring retrograde nail fixation and lumbar compression fractures. The DON acknowledged that the resident’s inconsistent pain reporting contributed to a delayed transfer to the ER and stated that the bed should not have been in the highest position during care. The NP confirmed awareness of the resident’s report of 10/10 pain after the fall and that the resident was sent to the hospital after a second X‑ray identified the femur fracture.
Failure to Ensure Trained Feeding Assistance, Pre-Op Instructions, and Timely Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for multiple residents. One resident with Parkinson’s disease, dysphagia, GERD, and protein-calorie malnutrition was care planned for an easy-to-chew diet with feeding assistance and had physician orders for medications to be given whole in applesauce or pudding. Activities documentation showed that activities staff fed this resident various desserts and snacks on multiple dates. The Activities Director stated that activities staff provided one-to-one support and feeding assistance and had received general feeding-assistance training. However, the Speech Pathologist reported that the resident had oral dysphagia and that a physician-ordered full swallowing evaluation from March of the prior year was never completed. The Speech Pathologist and the DON both confirmed that non-clinical staff assisting with feeding residents with dysphagia should have specialized training and competency validation, which the activities staff did not have. Another deficiency occurred when a resident with a diagnosis of rotator cuff injury and chronic pain was scheduled for shoulder surgery. The EHR contained a physician order for the surgery appointment, but there was no documentation of pre-operative instructions or that the resident had been educated on those instructions. The resident reported that the surgery could not be performed because he had eaten beforehand and stated that staff had not informed him of any pre-operative requirements. The DON confirmed that pre-operative NPO instructions had been received and were expected to be entered into the EHR and explained to the resident, but acknowledged that neither the instructions nor documentation of education were present in the record. A further deficiency involved a resident who experienced a witnessed fall and subsequently had persistent pain. Nursing progress notes documented a fall with immediate complaints of pain to the lower back, right leg and hip, and left arm. The provider was notified and orders were obtained for pain medication, labs, and x-rays, with initial imaging reportedly negative for acute injury. The resident continued to complain of pain, and a second x-ray several days later revealed a right femur fracture, after which the resident was sent to the emergency department. The DON and the NP both stated that the resident was not sent to the ER immediately after the fall and confirmed that residents with significant injuries such as a femur fracture should be sent to the hospital immediately.
Inaccurate MDS Coding for Hearing, Oxygen Use, and Functional Status
Penalty
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) for two residents, resulting in assessments that did not reflect their actual hearing status, oxygen (O2) use, and functional abilities. For one resident with metabolic encephalopathy, influenza A, acute respiratory failure with hypoxia, and acute pulmonary edema, surveyors observed that he repeatedly responded "huh" during attempted interviews and interactions, indicating difficulty hearing. Despite this, his MDS documented no difficulty in normal conversation or social interaction, no hearing aid in use, and an ability to understand others. The MDS also indicated receipt of speech-language pathology and audiology services, while physician orders and notes contained no documentation of hearing aids, audiology assessments, or hearing services, and physician notes described his speech as clear and that he was able to understand and be understood. An LPN stated the resident was hard of hearing and did not have hearing aids at the facility, and the DON later acknowledged she was unaware of any hearing issues and that the MDS hearing section was not accurate. The same resident’s MDS was also inaccurate regarding O2 use. Physician progress notes over January documented fluctuating O2 saturations, continued O2 supplementation, and use of O2 via nasal cannula at 2 LPM, with later notes indicating the resident was on room air. Nursing notes during this period alternately documented no O2 in use, room air, and O2 via nasal cannula. A physician order dated early February called for a room air trial to determine ongoing O2 need, and on observation the resident was seen on room air with an oxygen concentrator at the bedside that was off and without tubing attached. Despite this history of O2 use and changes, the resident’s MDS contained no documentation regarding O2 use. The DON stated it was her expectation that O2 use be documented in the MDS and confirmed the MDS was not accurate regarding O2 use. For a second resident with Parkinson’s disease, dysphagia, and scoliosis, nursing progress notes over several months documented that she was bedbound and dependent on all activities of daily living, with multiple entries describing her as bedbound and at baseline in that status. However, two MDS assessments during this period coded Section GG (Functional Abilities) to indicate that a wheelchair (manual or electric) was the mobility device normally used in the last seven days. Observations by surveyors found the resident to be bedbound, and the DON stated that the resident’s functional decline from wheelchair use to being bedbound should have been considered a change in condition, but she could not determine when the change occurred. The DON further stated that documentation showed the resident had been bedbound since 2023, that she did not recall the resident using a wheelchair, and that the MDS assessments were documented incorrectly because the resident could not use a wheelchair and required bedbound care. A significant change MDS was not completed despite this documented functional decline.
Inaccurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of the PASARR Level I Identification Screening for two residents with documented mental health diagnoses. For one resident, the face sheet showed an admission with diagnoses of anxiety disorder and major depressive disorder, recurrent severe without psychotic features. The resident’s care plan documented use of antianxiety and antidepressant medications related to these conditions and included monitoring for signs and symptoms of depression, such as crying, shame, worthlessness, agitation, irritability, and suicidal ideation. However, the PASARR Level I Identification Screening dated 09/16/25 documented that the resident did not have a diagnosis of or suspected mental illness. During interview, the Admissions Director acknowledged that the PASARR did not include the resident’s mental health diagnoses and stated that if the PASARR screening does not include all pertinent diagnoses, the resident may not be properly screened. For the second resident, the face sheet documented an admission with multiple readmissions following hospitalizations and included diagnoses of generalized anxiety disorder and major depressive disorder. Two separate PASARR Level I Identification Screenings, dated 12/21/24 and 12/11/25, both documented that the resident did not have a diagnosis of or suspected mental illness and did not list generalized anxiety disorder or major depressive disorder. The resident’s care plan documented use of hydroxyzine for anxiety disorder, goals related to decreasing signs and symptoms of anxiety, and monitoring for side effects and effectiveness of anti-anxiety therapy. In interview, the Admissions Director confirmed that these mental health diagnoses were not reflected on the PASARR screenings and stated that if diagnoses are missing, the PASARR process would be inaccurate and residents may not receive all required services or may be improperly placed and not have all of their mental health issues addressed and treated.
Failure to Update Care Plans for Wound, Hearing, and Oxygen Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive, person-centered care plans for two residents. One resident was admitted with multiple diagnoses including localized edema, morbid obesity, chronic diastolic heart failure, mixed hyperlipidemia, depression, and essential hypertension. A comprehensive MDS indicated this resident was at risk for developing pressure ulcers. Physician orders dated 09/13/2025 documented a sacral wound with ordered wound care treatment, and the resident reported the wound was acquired in the facility around September 2025. However, review of the care plan dated 09/14/2025 showed no wound care interventions for the sacral wound identified on 09/13/2025, and the DON stated the wound was first identified on 09/11/2025 and confirmed the care plan was not updated at the time of identification, with the first wound care plan entry not appearing until 11/13/2025. The second resident’s care plan dated 01/07/2026 lacked documentation of problems, goals, or interventions related to auditory assessment or hearing aids, despite issues with hearing and need for hearing aids referenced elsewhere. During interview, the DON stated she was unaware of communication issues and the need for hearing aids for this resident, and acknowledged it was her expectation that the resident’s difficulty hearing be included in the care plan so the team would be aware. The same resident’s care plan documented impaired gas exchange related to respiratory failure and pulmonary edema with several interventions, including adequate fluid intake, elevating the head of the bed, and monitoring for signs of infection, but did not include O2 use as an intervention. The DON confirmed that the resident’s O2 use was not included in the care plan and stated it should have been documented.
Failure to Complete AIMS Assessments, Provide Ordered Meal Assistance, and Use Appropriate Injection Equipment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards for residents receiving antipsychotic medications, assistance with meals, and injectable medications. One resident with schizophrenia, admitted in late November, had physician orders for Risperdal and Cogentin and demonstrated abnormal involuntary movements, including uncontrolled arm movements and frequent leg twitches. Record review showed only two AIMS assessments completed over several months despite the DON’s statement that AIMS assessments are to be done quarterly for residents on antipsychotics, and the DON acknowledged that the resident’s known abnormal movements should have been reflected on the AIMS tool. Another resident with major depressive disorder, dementia with severe behavioral disturbance, and suicidal ideations was ordered Aripiprazole along with antidepressants, yet record review revealed that no AIMS assessment had been completed since admission, which the DON confirmed should have occurred due to the antipsychotic use. The facility also failed to follow physician orders and the care plan for meal assistance for a resident with impaired physical functioning. This resident’s care plan documented a need for substantial/maximum assistance with eating, and a physician order directed staff to provide feeding assistance with every meal. During observation, the resident was seen eating alone in the room, and the meal ticket indicated a requirement for assistance/supervision for all meals. The ADON confirmed that the resident was care planned to receive assistance for all meals and acknowledged that no staff member was present during the observed meal, and the DON later confirmed that feeding assistance for every meal had been ordered and care planned but was not provided at that time. In addition, the facility did not use appropriate equipment for administering an injectable medication. A resident had a physician order for heparin 5,000 units per 1 mL, and during a medication pass observation, an LPN prepared and administered the heparin using an insulin syringe via subcutaneous injection in the abdomen. In a subsequent interview, the LPN stated that insulin syringes should only be used for insulin, but she used one for heparin because she had not been told to use other supplies and was unaware of other available injection supplies or their location. The DON later stated that insulin syringes are expected to be used only for insulin and confirmed that other injection supplies were available and that the insulin syringe should not have been used for the heparin injection.
Improper Medication Security and Unlabeled Lancet Storage
Penalty
Summary
The deficiency involves failure to ensure proper storage and security of medications and medical supplies. During an observation of the medication cart in the 500-hall at 8:39 am, several packs of one resident’s medications, including Pravastatin, Methocarbamol, and Buspirone, were found left unattended on top of the medication cart with no nursing staff present. The ADON confirmed that these medications should not have been left on top of the cart unattended, and the CMA responsible for the cart acknowledged she should have locked up the medications before walking away and confirmed they should not have been left unattended. Additional observations in the medication storage room for the 200, 300, and 400 halls at 2:36 pm revealed lancets had been removed from their original packaging and stored loosely in a large bin without labeling or expiration dates. In an interview at 2:37 pm, the DON stated that when the facility receives a new shipment of lancets, they are removed from the packaging and placed into a large bin, and confirmed that storing the lancets in this manner was unacceptable and should not be done.
Inconsistent Code Status Documentation in Advance Directives
Penalty
Summary
The facility failed to ensure that a resident’s advance directive information was accurate and consistent across the Electronic Health Record (EHR) and related documents. Record review showed that the resident’s face sheet listed the code status as Full Code at admission, indicating that lifesaving procedures were desired. The resident’s care plan, dated 11/03/25, also documented the resident as Full Code. However, the New Mexico Medical Orders for Scope of Treatment (NM MOST) form for the same resident, dated 05/05/23, identified the resident as Do Not Resuscitate (DNR), indicating that lifesaving measures were not desired. During an interview, the DON acknowledged that the NM MOST form documented the resident as DNR while the face sheet and care plan documented the resident as Full Code. The DON confirmed that the resident’s correct code status was Full Code and stated that her expectation was that a resident’s code status be accurate and consistent across all documentation. The DON further stated that the NM MOST form was inaccurate and should not have been, confirming the inconsistency in the resident’s end-of-life documentation.
Failure to Complete Significant Change MDS After Fall With Major Fractures
Penalty
Summary
The deficiency involves the facility’s failure to complete a Significant Change in Status MDS assessment following a resident’s major decline in condition after a fall with serious injury. The resident had a history of multiple vertebral compression fractures, bone density disorders, and a displaced condyle fracture of the femur. The record shows the resident experienced a witnessed fall and subsequently complained of pain in the lower back, right leg and hip, and left arm. The practitioner was notified and ordered topical pain medication, oxycodone, labs, and x‑rays. A physical therapy note documented that, a few days after the fall, the resident reported severe back pain rated 10/10 and ongoing head pain, and stated that a higher level of care was required due to decline in function, mobility, and independence. Further record review showed that an x‑ray follow‑up was positive for a right femur fracture, and the resident was sent to the emergency department. The resident was later readmitted after hospitalization, where she underwent ORIF for the right femoral fracture and was discharged back with a knee immobilizer and additional findings of lumbar spine compression fractures and bruising to the upper extremities. Despite these significant injuries, surgical intervention, and documented decline in functional status, the facility did not complete a Significant Change MDS until approximately one and a half months after the injury. In an interview, the DON confirmed that a Change in Condition MDS was not completed following discovery of the major injuries and acknowledged that it was her expectation that such an assessment should have been completed and submitted within 14 days.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and submitted within the required 14 days for one resident. The resident was admitted to the facility and later discharged to the hospital, but review of the electronic health record showed that the discharge MDS was not submitted and accepted until 123 days after the resident’s discharge. During an interview, the MDS Coordinator acknowledged that the discharge MDS for this resident was late, confirmed it was not completed until the following year, and stated that it should have been submitted within 14 days of the resident’s discharge but was not. The report notes that if MDS assessments are not completed and submitted in a timely manner, then the resident is likely to receive less than optimal care.
Failure to Update Care Plan to Reflect Accurate DNR Code Status
Penalty
Summary
Facility staff failed to revise a resident’s care plan to accurately reflect the resident’s advance directive code status. Record review showed the resident was admitted on 12/12/25 with a documented code status of Do Not Resuscitate (DNR) on the face sheet, and the New Mexico Medical Orders for Scope of Treatment (NM MOST) form dated 01/28/26 also identified the resident as DNR. However, the resident’s care plan dated 01/26/26 listed the resident as Full Code, indicating a desire for all possible life-saving interventions. During an interview on 02/06/26, the DON confirmed that the resident’s advance directive care plan was inaccurate and should have been updated to match the NM MOST form. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.
Unauthorized Wound VAC Order Changes and Improper Implementation of Surgical Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to promote healing of a surgical wound for one resident with a deep incisional surgical site infection. The resident was admitted with hospital discharge orders directing that a wound VAC remain on the incision continuously for six days at 125 mmHg. The resident’s care plan identified a surgical wound and directed staff to provide wound care as ordered. However, when the orders were entered into the facility’s system, they were altered from the hospital discharge instructions. A subsequent physician order dated two days after admission directed staff to remove the wound VAC dressing and foam, cleanse and dry the wound, reattach the hose to the wound VAC, and initiate therapy at 125 mmHg continuous suction with wound care to be provided three times weekly. This order differed from the hospital’s directive to keep the wound VAC on continuously for six days. The Assistant DON independently changed the wound care orders without provider authorization, which was later confirmed by the DON. The facility’s Treatment Administration Record showed that the wound care order was carried out only once during the month, indicating that the prescribed wound VAC therapy was not implemented as intended. Nursing documentation noted that the wound VAC device was found set at 190 mmHg with no suction at the wound site and drainage observed under the dressing. During an interview, the DON stated she observed the same issues and that the resident’s wound had worsened, with the sutures dehiscing. The resident recognized that the wound did not look right and contacted her surgeon directly. The Nurse Practitioner reported she was not aware the wound had worsened and stated her expectation that hospital orders be entered as received unless a provider approved changes, confirming that the ADON should not have altered the wound VAC orders or settings without authorization.
Failure to Provide Ordered Oxygen Therapy and Maintain Readily Available O2 Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards for two residents who required or potentially required oxygen (O2) therapy. For one resident with impaired gas exchange related to respiratory failure and pulmonary edema, physician progress notes over several weeks documented fluctuating O2 needs, including low O2 saturations on room air, use of O2 at 1–4 LPM, and instructions to continue O2 supplementation and wean as tolerated. However, on the date of survey observation, the resident was seen outside the room without O2, and the bedside oxygen concentrator was present but turned off and without tubing attached. The physician’s orders on that date referenced only a room air trial, with no active or discontinued O2 orders in the record. Nursing progress notes were inconsistent, alternately documenting no O2 in use and O2 via nasal cannula on different days, and the resident’s care plan, while addressing impaired gas exchange, did not include O2 use as an intervention. The MDS for this resident also lacked documentation of O2 use. The DON stated her expectation that O2 use be ordered in the EHR and reflected in the care plan and MDS. For the second resident, admitted with Parkinson’s disease, dysphagia, and weakness, physician orders directed O2 at 1–4 LPM via nasal cannula as needed. Despite this standing PRN order, surveyors twice observed that no O2 equipment was present in the resident’s room on separate days. During interview, the DON confirmed that the resident had an order for O2 at 1–4 LPM as needed and stated her expectation that appropriate O2 equipment should be present and available in the resident’s room. These findings show that the facility did not ensure ordered O2 therapy was administered per provider orders for one resident and did not ensure necessary respiratory equipment was readily available for another resident with an active O2 order.
Failure to Provide Required Dental Services and Assess Oral Health Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide access to routine and emergency dental services for a resident in accordance with its own Dental Services Policy and the resident’s physician orders and care plan. The facility’s policy from 2018 states that routine and 24-hour emergency dental services are available through a contracted dentist who comes to the facility monthly. The resident was admitted with multiple diagnoses, including Parkinson’s disease, dysphagia, GERD without esophagitis, and unspecified protein-calorie malnutrition. Physician orders dated 05/19/23 directed that the resident receive dental evaluation and treatment as indicated, and the care plan dated 11/27/24 documented that the resident was dependent on assistance with oral hygiene. Multiple MDS assessments documented that the resident required supervision or touching assistance for oral hygiene. Despite these orders and assessments, review of the electronic health record as of 02/04/26 showed no documentation that the resident had ever received a dental evaluation or treatment since admission. A progress note dated 12/29/25 listed multiple oral health areas, including dentures, mouth tissue, natural teeth, cavities, gums, and pain or difficulty chewing, all marked as “Not Assessed.” On observation, the resident was noted to have broken teeth with visible plaque buildup and discoloration, and in interview the resident reported not having seen a dentist since before admission and experiencing dental pain that staff were aware of. The DON confirmed in interview that the resident had not received dental services since admission due to the facility’s inability to secure mobile dental services and the resident being bedbound and unable to transfer to a wheelchair for outside appointments, and acknowledged that the resident should have had a dental evaluation and/or treatment but did not.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently and accurately documented across all medical records. Upon review, the resident's face sheet did not include any code status, while the hospital discharge documentation and the New Mexico Medical Orders for Scope of Treatment (NM MOST) form both indicated a Do Not Resuscitate (DNR) status. However, the resident's care plan listed a Full Code status. During the admission process, a family member was informed by a nurse that the resident was a full code, despite the family member's knowledge of a DNR status from the hospital. The Director of Nursing confirmed that the facility presumes full code status if no documentation is present and acknowledged the inconsistency in the resident's records.
Unsecured Electrical Panels, Tripping Hazards, and Unsafe Items in Resident Areas
Penalty
Summary
Staff failed to maintain a safe environment free from accident hazards, as evidenced by several observations throughout the facility. An unsecured electrical junction box with exposed wires and circuit boards was found within reach of residents in a hallway, and staff were not present in the area. Multiple electrical cords, including a power cord and a coaxial cable for a power wheelchair, were left unattended and stretched across the hallway floor, creating a tripping hazard. Additionally, the fire alarm control panel in the main hallway was observed open with exposed wires and components, accessible to residents and without staff supervision. In a resident's room, a large kitchen knife was found on a desk and an open can of WD-40 was on the nightstand. The resident stated the knife was used to cut fruit and the WD-40 was for wheelchair maintenance. Facility staff, including the ADON and Maintenance Director, confirmed that the fire alarm panel, electrical boxes, and hazardous items such as knives and chemicals should be secured at all times to prevent resident injury or tampering. These conditions were not in accordance with the facility's policy on hazardous areas, devices, and equipment.
Resident Physically Restrained and Struck by Nurse During Exit Attempt
Penalty
Summary
A deficiency occurred when a nurse physically intervened to prevent a resident with paraplegia, depression, and PTSD from leaving the facility. The resident attempted to exit to the parking lot late at night, and the nurse tried to push the resident back inside. During the incident, the resident grabbed onto the door frame, and the nurse swatted at the resident's hands to make him release his grip. Security camera footage confirmed the nurse's actions, and the resident subsequently called the police to report the incident as abuse. The resident reported feeling scared and unsure of the staff following the event, and expressed ongoing distress, including thoughts of suicide. The facility's investigation substantiated that the nurse violated the resident by slapping his hands during the altercation. The incident was reported to the State Agency, and the facility acknowledged the violation after reviewing the evidence.
Failure to Accurately Investigate and Document Abuse Allegation
Penalty
Summary
The facility failed to conduct an accurate and thorough investigation into an allegation of abuse involving a resident. According to the records, the resident called the police to report abuse after a nurse attempted to prevent him from leaving the facility late at night. The nurse involved was placed on administrative leave pending the outcome of the investigation. The facility's Five Day Follow-Up Report, which was submitted to the State Agency, included information that the resident was frequently outside the facility, had interactions involving suspected drug use, and had been sent to the emergency room for suspected overdoses. However, a review of the resident's electronic medical record did not show any documentation of these incidents, including suspected overdoses, administration of Narcan, or emergency room visits for overdose. During an interview, the Administrator who authored the Five Day Follow-Up Report admitted he could not verify that the resident had been sent to the emergency room for a suspected overdose and stated he may have confused this resident with another. This resulted in the submission of an inaccurate report to the State Agency, as the information provided did not match the resident's documented medical history. The lack of accurate documentation and investigation into the abuse allegation prevented the State Agency from appropriately reviewing the incident for further investigation.
Inaccurate MDS Assessment for Resident with Behavioral and Mental Health Concerns
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a diagnosis of depression. The resident's MDS assessment did not reflect any behavioral concerns, physical or verbal inappropriate behaviors, suicidal or homicidal ideations, or rejection of care. However, multiple other records, including the care plan, nurse progress notes, and a change in condition form, documented that the resident exhibited drug-seeking behavior, hypersexuality, verbally abusive behavior, and both suicidal and homicidal ideations. The care plan specifically noted risks related to these behaviors, and nurse progress notes described the resident expressing feelings of depression, danger to self, and explicit statements about suicidal and homicidal thoughts. Further documentation included a change in condition form noting behavioral symptoms and depression, as well as interviews with the resident, DON, and Administrator confirming ongoing behavioral and mental health concerns. The resident himself reported ongoing suicidal thoughts and a desire to end his life, while facility leadership acknowledged issues with aggressive, inappropriate, and drug-seeking behaviors. Despite this, the MDS assessment failed to capture these significant behavioral and mental health issues, resulting in an inaccurate assessment.
Unattended and Unlocked Treatment Cart on 600 Unit
Penalty
Summary
Staff failed to secure a wound care treatment cart on the 600 Unit, leaving it unlocked and unattended on multiple occasions. Observations revealed that the cart contained wound care items such as mineral oil, tweezers, and scissors, and was left open without staff present in the area. This occurred on at least two separate occasions, as documented during surveyor rounds. Interviews with staff, including a registered nurse, a certified medication technician, and the director of nursing, confirmed that it was the responsibility of nursing staff to ensure the treatment cart was locked when not in use. All interviewed staff acknowledged that the cart should not be left unlocked and unattended, yet the practice was observed more than once, affecting the entire 600 Unit.
Failure to Report Allegations of Neglect or Abuse
Penalty
Summary
The facility failed to report allegations of possible neglect or abuse for three residents. The Administrator was aware of the allegations but did not report them to the State Agency. The incidents involved a Certified Nurse Aide and a resident, where no sexual contact was indicated, and medication errors involving two other residents. The Administrator believed these incidents did not rise to the level of abuse, neglect, or mistreatment, and therefore did not report them, despite generally over-reporting incidents to the state agency.
Failure to Investigate and Report Allegations of Abuse and Mistreatment
Penalty
Summary
The facility failed to conduct thorough investigations and report findings within five working days for allegations of abuse and mistreatment involving three residents. For one resident, a medication error occurred when they were given the wrong medications, leading to choking and coughing. Emergency services were called, and the resident was assessed but required no further care. However, the incident was not documented in the facility's reportable incidents, nor was it reported to the state agency or investigated by the facility. Another resident was involved in an incident of alleged sexual misconduct by a staff member. The Assistant Director of Nursing (ADON) observed inappropriate physical contact between a Certified Nurses Aide (CNA) and the resident on two occasions. The ADON reported the incident to the Director of Nursing, and the CNA was reassigned to a different area. Despite these actions, the incident was not documented in the facility's reportable incidents, reported to the state agency, or further investigated. A third resident filed a grievance regarding a medication error, which was acknowledged by the ADON. The medication error was investigated internally, and the nurse involved was re-educated. However, the incident was not documented in the facility's reportable incidents or reported to the state agency. The facility administrator was aware of all three incidents but did not report them to the state agency, as he did not believe they constituted abuse, neglect, or mistreatment.
Failure to Maintain Sanitary Food Storage Practices
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during a survey. Several food items in the kitchen were not labeled or dated, including a 3.5-liter container of sliced tomatoes, a plastic container of sliced onions, and packages of Conestoga Pioneer 6 extra crisp English muffins. Additionally, items meant to be stored frozen, such as Hilltop Hearth Homestyle Waffles, were found in the refrigerator instead of the freezer. Other items, like a package of Roseli pepperoni and hamburger buns, were also not labeled or dated. These observations were confirmed by the Dietary Manager, who acknowledged that all food should be labeled, dated, and stored appropriately. Further deficiencies were noted in the unit nourishment rooms. In the skilled unit nourishment room, a Styrofoam cup of white liquid and a plastic bag of salad kit and croutons were not labeled or dated. Similarly, in the long-term care unit nourishment room, a 2-pack pepperoni pizza hot pocket and a 1.5-quart container of Breyers ice cream were improperly stored. The Dietary Manager confirmed these findings as well, reiterating that each food and beverage item should be labeled and dated. These failures have the potential to result in cross-contamination, the growth of foodborne pathogens, and foodborne illness, affecting all residents consuming food from these areas.
Failure to Safeguard Residents' PHI
Penalty
Summary
The facility failed to safeguard clinical record information, resulting in unauthorized access to residents' Private Health Information (PHI). During a random observation on the 500 wing, a vital sign sheet containing all residents' vital signs was left face up on the nurses' station counter, accessible to unauthorized individuals. A Certified Nurse Aide (CNA) confirmed that such information should not be left exposed. Additionally, on the 300 unit, a Registered Nurse (RN) left a computer open to the Medication Administration Record (MAR) while walking away from the medication cart, which was verified by the RN as a breach of protocol. Further observations revealed that a vital sheet on the 500 wing was left unattended on a medication cart, and a clipboard with a resident's neuro check form was left face up on the counter at the nurses' station, both accessible to unauthorized persons. These incidents were confirmed by staff members, including a CNA, who acknowledged that the information should not have been left exposed. These actions and inactions led to the deficiency of failing to protect residents' PHI from unauthorized access.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, as observed during a survey. Meal trays from breakfast were left in the residents' rooms well past the meal service times, with trash and old food still present on the trays. This was observed in the rooms of three residents, who expressed frustration over the situation. The presence of these trays in the rooms was confirmed by a registered nurse, who acknowledged that the trays should have been collected earlier. The Director of Nursing also confirmed that the expectation was for the nursing staff, including CNAs, to collect the meal trays sooner. The failure to remove the trays in a timely manner resulted in an environment that was not clean or comfortable, as required by the residents' rights to a homelike setting. This deficiency was identified through observations, record reviews, and interviews with the staff and residents involved.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for two residents, focusing on their activity preferences. Resident #45 was admitted with multiple diagnoses, including metabolic encephalopathy, depression, chronic kidney disease, and generalized anxiety disorder. Despite an activities assessment indicating preferences for religious services, being outside, and listening to music, the care plan dated 09/24/24 did not include any provisions for these activities. Similarly, Resident #195, who was admitted with conditions such as non-traumatic intracerebral hemorrhage, depression, vascular dementia with agitation, and hemiplegia, had an activities assessment showing a preference for family interaction and group activities. However, the care plan dated 10/16/24 lacked any reference to these preferences. The Activities Director acknowledged completing assessments for all residents but admitted to not updating their care plans, leading to the deficiency.
Failure to Update Care Plans for ADL Assistance and Hospice Services
Penalty
Summary
The facility failed to update the care plan for a resident who required significant assistance with activities of daily living (ADL). The resident, who had diagnoses including aphasia, dysphagia, and traumatic brain injury, was dependent on staff for assistance. Despite this, the care plan did not specify the number of staff required for ADL assistance. Interviews with a CNA and an RN confirmed that the resident needed extensive assistance, often requiring at least two CNAs for transfers. The Director of Nursing acknowledged that the care plan should have included this information. Additionally, the facility did not update the care plans for two residents who were receiving hospice services. One resident was admitted to hospice due to severe calorie malnutrition, and another due to diastolic congestive heart failure and respiratory failure. Despite being on hospice, their care plans did not reflect this service. Interviews with hospice staff and the Director of Nursing confirmed the oversight, with the DON unaware of the policy for care planning related to hospice services.
Deficiencies in Medication Administration and Resident Care Planning
Penalty
Summary
The facility failed to provide quality care that meets professional standards for two residents. For the first resident, who has diabetes, the facility did not complete an assessment or obtain physician orders to allow the resident to self-administer insulin and check blood sugar levels under staff supervision. Despite the resident's ability to perform these tasks, as confirmed by interviews with the resident and staff, there was no documented assessment or physician order authorizing this practice. This oversight was acknowledged by both the Nurse Practitioner and the Director of Nursing, who confirmed the necessity of such documentation. For the second resident, who was diagnosed with COVID-19 among other conditions, the facility failed to administer an antiviral medication, Molnupiravir, as ordered by the resident's provider. The medication was supposed to be administered twice daily for five days, starting on the first day of the order. However, due to unavailability, the medication was not administered for the first three days. There was no record of the provider being notified about the unavailability, and the medication order was not amended to extend the administration period. This lapse was confirmed by the Director of Nursing, who noted the absence of documentation indicating that the provider was informed of the issue. These deficiencies highlight the facility's failure to adhere to professional standards in medication administration and resident care planning. The lack of proper documentation and communication with healthcare providers resulted in residents not receiving appropriate care as per their medical needs and provider orders.
Failure to Address Pharmacist Recommendations in Medication Reviews
Penalty
Summary
The facility failed to ensure that physicians responded to recommendations made by the consulting pharmacist during the monthly drug regimen reviews for six residents. The pharmacist's recommendations, which included suggestions for additional lab testing, gradual dose reductions of psychotropic medications, and updates to medication orders, were not properly addressed by the physicians. Instead, these recommendations were signed off by the former Director of Nursing (DON) or a Licensed Practical Nurse (LPN) without obtaining the necessary physician responses or rationales. The report highlights several instances where the pharmacist's recommendations were not followed up with appropriate physician responses. For example, recommendations for gradual dose reductions of medications like Mirtazapine, Sertraline, and Duloxetine were marked as refused by the physician without any rationale provided. Additionally, recommendations for reviewing the duration of PRN medication administration and updating diagnoses to support therapy were not addressed by the physicians, leaving the medication regimens potentially unevaluated. During an interview, the Assistant Director of Nursing (ADON) confirmed that the pharmacist's recommendations were supposed to be reviewed by the resident's assigned provider, who would then provide a rationale and sign off on each recommendation. However, the ADON acknowledged that this process was not followed, as the recommendations were signed by the former DON or an LPN without the required physician input. This oversight could lead to improper evaluation of residents' medication regimens, potentially resulting in over-medication.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 14.71% error rate observed during a medication administration review. Certified Medication Aide (CMA) #1 administered morning medications to a resident, including Amlodipine, Aspirin, Colecalciferol, Hydrochlorothiazide, and Lisinopril, at 9:37 am, which was outside the prescribed administration time of 8:00 am. The facility's policy allows for medications to be administered within a two-hour window, from one hour before to one hour after the scheduled time. However, the CMA delayed the administration to obtain the resident's blood pressure, resulting in a deviation from the prescribed schedule. The resident's Medication Administration Record (MAR) indicated that all medications were to be given at 8:00 am for conditions such as high blood pressure and vitamin deficiency. The facility's administrator confirmed the policy of administering medications within a specific time frame but noted that morning medications could be given between 7:00 am and 11:00 am. Despite this policy, the delay in administration led to a medication error rate exceeding the acceptable threshold, highlighting a deficiency in adhering to the prescribed medication schedule.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences by not ensuring the resident had access to her call light. The resident, who was admitted to the facility with left-sided hemiplegia and impaired gait, required a call light pad to be within reach as per her care plan. During an observation, the resident was found sitting in a wheelchair next to her bed with the call light pad placed on the opposite side of the bed, out of her reach. The resident expressed that she could not reach her call light pad and that staff should have placed it closer. A Certified Nursing Assistant confirmed that the call light pad was not within reach and should have been placed closer to the resident. The Director of Nursing also stated that the call light pad should be within reach of the resident at all times when she is in her room.
Inaccurate PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for a resident, which is crucial to prevent inappropriate placement in nursing homes. The resident's PASRR Level 1 Identification Screen indicated a need for a referral to PASRR Level 2 prior to admission. However, upon review, there was no documentation of a PASRR Level 2 referral in the resident's Electronic Health Record. Interviews with the Social Services Director and the Administrator revealed that the PASRR Level 2 referral was not completed before the resident's admission, and the PASRR Level 1 was incorrect. The Administrator acknowledged that the facility should have verified the accuracy of the PASRR Level 1 before admitting the resident.
Failure to Timely Schedule Vision Services
Penalty
Summary
The facility failed to ensure a resident received proper treatment to maintain vision, as evidenced by the case of a resident who required an optometry appointment for eyeglasses. The resident was admitted to the facility, and a physician order dated 09/13/24 indicated the need for an optometry appointment. However, a review of the resident's Electronic Health Record revealed that no such appointment had been scheduled or completed. During an interview, the resident expressed frustration over the delay in receiving glasses, which he needed to see. The Social Services Director confirmed that the appointment was not scheduled until 10/15/24, despite the physician order being dated a month earlier. The Director of Nursing also acknowledged that the appointment should have been scheduled sooner.
Unsecured Electric Cord Poses Tripping Hazard
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not securing an electric cord that posed a tripping hazard. During an interview, the resident reported that a Certified Nursing Assistant (CNA) tripped over the unsecured electric cord while repositioning him, although the CNA managed to avoid falling completely, she did bump into the side of the bed. An observation confirmed that the black electric cord was indeed unsecured and directly in the walking path to the resident's bedside. A Licensed Practical Nurse (LPN) verified the presence of the tripping hazard, confirming the deficiency in maintaining a hazard-free environment.
Failure to Provide Respiratory Care for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), which necessitated the use of a CPAP or Bi-PAP device. Upon review, it was found that the resident was admitted with a CPAP device, which was later substituted with a Bi-PAP by the family. However, there were no provider orders for the use, monitoring, or maintenance of either device until two weeks after the resident's admission. The resident's wife indicated that she was responsible for setting up the equipment each night, and it was unclear if the facility staff were aware of the resident's requirements for nightly use of the CPAP/Bi-PAP equipment. The Director of Nursing confirmed that there were no orders for staff to monitor or maintain the CPAP/Bi-PAP equipment prior to the date when the orders were finally entered. This oversight meant that the facility staff did not assist or manage the resident's respiratory equipment as required, potentially impacting the resident's therapeutic outcomes. The lack of timely provider orders and staff involvement in managing the resident's respiratory care represents a deficiency in the facility's responsibility to ensure safe and appropriate care.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, which is a violation of the requirement to store drugs and biologicals securely. On November 14, 2024, at 9:23 PM, a nurse was observed leaving the 300 wing medication cart unlocked and unattended. During an interview, the nurse confirmed that medication carts should not be left unlocked. Similarly, at 9:24 PM, the 500 wing medication cart was found unlocked and unattended, with a cup containing four unidentified medications and five lancets on top of the cart. Another nurse confirmed the cart should not be left unlocked and unattended but proceeded to walk away again without securing it. The Assistant Director of Nursing also confirmed on November 15, 2024, that the medication carts were left unlocked, acknowledging that they should not be left in such a state.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that a resident received routine dental care, which was necessary due to dental pain and recurrent gingivitis. The resident was admitted to the facility and had a physician's order dated 10/20/24 for a referral to an in-house dentist. However, the Electronic Health Record showed no indication that the resident was seen by a dentist following this order. The resident reported experiencing pain and needing several teeth pulled, and confirmed informing the nursing staff about her condition. The Social Services Director acknowledged that the in-house dentist canceled their contract shortly after the order was placed, and the resident had not been seen by a dentist as required. The Director of Nursing also confirmed that the resident should have been seen sooner than scheduled.
Infection Control Deficiencies in Nebulizer Storage and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection prevention measures for two residents. For one resident, the nebulizer mask was not stored appropriately in a bag, as observed during an interview and record review. The resident's nebulizer mask was found lying on the nightstand instead of being stored in a sealed bag, which is necessary to keep it clean. The resident expressed that they were never given a bag for storage, and this was confirmed by a registered nurse who acknowledged that the mask should be stored in a bag. The Director of Nursing also confirmed that the nebulizer mask should be cleaned, taken apart to dry, and stored in a bag. Additionally, during medication administration, a Certified Medication Aide (CMA) was observed using her bare fingers to pour medications for another resident. The CMA used her index finger to push pills from medication bottles into a medication cup, which is not a proper infection control practice. The CMA admitted to using her bare finger due to difficulty in removing the pills from the bottle. The Director of Nursing stated that staff should not use their bare fingers to touch and transfer medication from a bottle to a resident's medication cup.
Incomplete Medical Records for Resident Receiving Skilled Care
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident who was admitted for skilled care services due to severe cervical stenosis. The resident had multiple diagnoses, including Type 2 Diabetes, spinal stenosis in the cervical and lumbar regions, a flaccid neuropathic bladder, urinary retention, and a history of repeated falls. Despite being admitted for skilled care, the resident's medical records lacked daily notations of their admission, condition upon admission, needs at the time of admission, and skilled care provided. This lack of documentation persisted from the date of admission until a comprehensive skilled assessment was completed on the third day. On the day of discharge, the resident was noted to be drowsy, slow to respond, and had a low blood sugar level of 68. Medication was administered to increase blood sugar, resulting in mild improvement. However, the resident's status continued to decline, leading to a transfer to the hospital emergency room for evaluation. The Director of Nursing confirmed that the medical record was inadequate, lacking daily skilled care notes and a clear understanding of the resident's daily care, pain needs, and changes in condition, particularly on the day of transfer to the hospital.
Shower Gurney Collapse Due to Missing Pin
Penalty
Summary
The facility failed to ensure that patient care equipment was in safe operating condition, resulting in an incident involving a resident with quadriplegia and a traumatic brain injury. The resident was being transferred from his room to the shower room on a shower gurney when the gurney collapsed. This occurred because a pin that supports the head of the gurney was missing, causing the head to fall and the resident to slip from the gurney to the ground. The incident was confirmed through interviews with the LPN and CNA involved, as well as the resident, who recalled the fall and stated that he was not injured but was frightened by the event. The CNA demonstrated that the shower gurney was made of heavy tubes with a thick foam mattress, and the head of the gurney could be released by removing a pin. At the time of the accident, the pin was missing, leading to the collapse. The Assistant Director of Nursing and the Administrator confirmed the equipment failure and acknowledged that the gurney had since been repaired. They also confirmed that staff had been educated to check the equipment before use to ensure all parts are in place and secure.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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