Uptown Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 7900 Constitution Avenue Ne, Albuquerque, New Mexico 87110
- CMS Provider Number
- 325042
- Inspections on file
- 35
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Uptown Rehabilitation Center during CMS and state inspections, most recent first.
A resident with osteomyelitis and cellulitis of the lower limb did not receive a newly prescribed doxycycline antibiotic after a podiatry visit, despite facility staff being aware of the order and the need for treatment. The prescription was sent to an outside pharmacy but was never ordered by the facility, and the medication was not administered during the days following the prescription. The resident reported ongoing swelling, pus pockets, and severe pain and stated that staff were informed of the need for the antibiotic. The discharge medication list did not include doxycycline, and the resident was discharged without documented access to the prescribed antibiotic, as later confirmed by the DON.
Dietary staff and management failed to wear hairnets while preparing and serving food in the kitchen, as confirmed by direct observation and staff interviews. This resulted in food not being prepared and served under sanitary conditions, affecting all residents in the facility.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A nurse left the medication cart's computer screen unlocked and displaying a resident's medical information while unattended in a hallway with other staff and residents present. The unit manager intervened and reminded the nurse to secure the screen, and the administrator confirmed this was not in line with facility expectations.
A resident with diabetes did not receive care in accordance with physician orders when staff failed to administer Insta-Glucose as directed for low blood sugar episodes. Instead, staff sometimes provided other forms of sugar, such as juice or candy, contrary to the specific order. Interviews confirmed that the expectation was to follow the physician's order for Insta-Glucose, but this was not consistently done.
A resident with COPD and other chronic conditions experienced multiple episodes of hypoxia and respiratory distress. Although telehealth providers ordered albuterol nebulizer treatments, staff did not enter these orders into the medical record or document administration of the treatments. Facility leadership confirmed the absence of required documentation, resulting in uncertainty about whether the resident received the prescribed respiratory care.
A nurse left a medication cart unlocked and unattended while entering a resident's room, with other residents and staff present in the hallway. The Unit Manager later secured the cart and reminded the nurse of the requirement to keep it locked when not in use. The Administrator confirmed the cart should not have been left unattended.
Staff did not serve meals as listed on the menu and failed to offer residents the opportunity to select their meal choices in advance. A resident was served a meal not on the menu and reported ongoing dissatisfaction with incomplete and incorrect meals, while the Dietary Manager confirmed that residents were not asked for their preferences ahead of time and were not informed of substitutions.
Surveyors found that the outside dumpster used for kitchen and facility waste was repeatedly left uncovered and full of garbage. Both the Maintenance Director and Dietary Manager confirmed that all trash is disposed of in this dumpster and acknowledged that it should be kept covered, but staff failed to do so.
The facility did not maintain complete documentation for its infection surveillance plan, lacking procedures for monitoring, early detection, and management of infections, as well as evidence-based surveillance and data analysis. Leadership interviews revealed that new staff in key roles did not receive necessary documentation or guidance from predecessors, and the Medical Director was not regularly involved in infection surveillance activities.
The facility did not implement a comprehensive Antibiotic Stewardship Program (ASP) as required, lacking written protocols for antibiotic prescribing, review processes, and feedback systems. Leadership and key staff confirmed the absence of ongoing monitoring and annual review of antibiotic use, and the Medical Director was not actively involved in ASP oversight. The Consultant Pharmacist conducted monthly medication reviews but noted the facility had not established an ASP.
Staff did not ensure a clean, safe, and comfortable environment, as evidenced by broken blinds, missing wall tiles, unpainted drywall, dusty ceiling fans, stained tablecloths, dirty vending machines, and unsanitary conditions in a conference room used for care plan meetings. Maintenance and housekeeping staff cited lack of time, incomplete inspection routines, and missing items as reasons for these deficiencies.
Staff did not update care plans for two residents to reflect changes in their need for specific eating utensils. One resident with dementia and a history of suicidal thoughts was observed using a metal fork despite the care plan specifying plastic utensils, while another resident on a pureed diet used a regular-sized spoon instead of the small spoon listed in the care plan. Both the Administrator and DON confirmed that care plans were not revised as required.
Staff did not consistently follow safety protocols, including proper smoking supervision for a resident with dementia, secure storage of lighters, and removal of staff personal belongings from resident rooms. Additionally, unsecured bleach wipes were left accessible in a resident bathroom, increasing the risk of exposure to hazardous substances.
Nurses and CMAs did not consistently discard opened insulin pens within 28 days as required by manufacturer instructions and facility policy. Multiple insulin pens for several residents were found on the medication cart past the 28-day period, despite staff and management acknowledging the requirement to label and discard them appropriately.
Surveyors found that food was stored uncovered, unlabeled, and undated in the kitchen, with additional issues such as open containers, dirty equipment, and poor cleanliness throughout food storage and preparation areas. Dietary staff were observed serving food without hair restraints and handling drinks by the rims of cups with bare hands, contrary to facility policy. These practices were confirmed by staff interviews and could affect all residents in the facility.
Staff failed to report and repair two nonfunctional call lights in a shower room, leaving them without cords and inaccessible for use. Additionally, a resident with mobility impairments was observed twice with their call light on the floor and out of reach, preventing them from requesting assistance. Staff interviews confirmed awareness of the issue but a lack of timely reporting or correction.
Surveyors identified several environmental safety and maintenance deficiencies, including a damaged oxygen storage room door that could be easily opened, a fire door that failed to close during a fire alarm, rusted door frames in a resident's bathroom, multiple ceiling tiles with holes or cracks, and broken electrical outlets in common areas. The Maintenance Director was unaware of some issues and relied on staff work orders for repairs, with some areas lacking clear maintenance policies.
A resident's advance directive status was not properly updated in the medical record after a change from Do Not Resuscitate (DNR) to Full Code was made on the MOST form. The discrepancy was identified when the Unit Manager confirmed that the medical record still reflected the outdated DNR status, despite the resident's current wishes for lifesaving procedures.
A resident with a history of alcohol use disorder and Alzheimer's disease had inconsistent cognitive assessments documented in the MDS, with staff interviews confirming that one assessment was coded incorrectly and did not match the resident's actual cognitive status. This resulted in a failure to ensure an accurate and comprehensive MDS assessment.
A resident receiving continuous oxygen therapy had oxygen tubing and a humidifier bottle in use that were not labeled with the date or staff initials, contrary to physician orders and facility protocol. Staff interviews confirmed that labeling was not performed as required when the equipment was changed or on admission.
Two residents did not receive routine dental care as required, with one lacking properly fitting dentures and the other exhibiting decayed teeth and bleeding gums. Both had documented risks for oral health problems and physician orders for dental referrals, but neither had follow-up dental appointments. The unit manager confirmed lapses in dental care and difficulties securing consistent dental providers.
A resident with Type II diabetes did not receive Insta-Glucose gel as ordered by their physician when their blood glucose levels fell below 70 mg/dL. Despite specific orders, staff provided alternative treatments like juice or snacks. Interviews with the Unit Manager, DON, and nurses highlighted a failure to adhere to the physician's orders, leading to the identified deficiency.
A resident with complex medical conditions, including quadriplegia and severe pain, was left calling out for pain medication for about 30 minutes without adequate response from staff. A visitor overheard a staff member yelling at the resident, dismissing her requests. The resident felt ignored and was in significant pain, leading to frustration. A CNA admitted to raising her voice, claiming it was necessary due to the resident's constant yelling, and was confronted by a visitor for aggressive behavior.
A facility failed to report an abuse allegation involving a CNA and a resident with complex medical conditions to the SSA. The incident was reported by visitors to the SSD, who initiated an investigation and suspended the CNA but did not notify the SSA. The Administrator was unaware of the incident due to being absent, resulting in a deficiency in the facility's reporting procedures.
A resident with complex medical conditions experienced unmanaged pain due to inconsistent administration of prescribed Oxycodone. Despite having a care plan, the medication was often unavailable, and staff failed to obtain it from the Pyxis machine. This led to significant pain and emotional distress for the resident.
A resident with multiple health issues, including neuropathies and dementia, did not receive podiatry care as ordered by a physician. Despite a podiatry consult being ordered, there was no documentation of a podiatrist visit, and the resident's toenails remained long and yellow, with swelling observed. Staff interviews revealed that the resident often refused assistance and wore socks, which contributed to the oversight. The facility's Administrator assumed the podiatrist had seen the resident, but the podiatrist had not visited the facility for several months.
The facility failed to update medical records with necessary documents and accurate information for two residents regarding foot care. One resident requested a podiatrist but refused care, and the EMR lacked documentation of the visit or refusal. Another resident's EMR did not contain podiatry notes or refusals after a previous visit, and the resident managed his own nail care. The administrator confirmed the lack of documentation for both residents' refusals.
The facility experienced staffing shortages, impacting the ability to provide scheduled baths or showers to all 116 residents. An LPN noted issues during the night shift, while an anonymous staff member and an RN confirmed frequent missed hygiene care due to understaffing. The DON acknowledged the staffing challenges.
The facility failed to maintain a clean and homelike environment on the 400 Unit. Observations revealed mattresses and an oxygen concentrator in the hallway near a room, and a bedside commode outside another room. Staff confirmed these items should not have been left in the hallway, and the Administrator acknowledged the issue.
The facility failed to provide timely care and assessment for a resident upon admission, delaying hydration and assessment for several hours. Additionally, another resident's PICC line care was neglected, with no physician orders for monitoring or dressing changes documented, leading to a lack of proper care until discharge. These deficiencies highlight lapses in adherence to professional standards and protocols.
The facility failed to provide scheduled assistance with activities of daily living (ADL) for five residents, particularly in bathing and showering. Despite care plans indicating the need for regular bed baths or showers, staff did not consistently offer or provide these services. Interviews and documentation revealed that residents did not refuse care, and the DON confirmed the failure to meet hygiene needs.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in medication administration documentation. One resident's MAR inaccurately showed administration of an inhaler that was not used, while another resident's records indicated administration of unavailable medications. Interviews revealed staff were unaware of these discrepancies, and the DON emphasized the need for accurate documentation and provider notification when medications are unavailable.
A resident's check for $800 was stolen from her dresser, and the facility failed to offer a secure place for her belongings until after the theft. The Business Office Manager confirmed the check was cashed via mobile deposit, and a fraud claim and police report were filed. The Administrator admitted that providing a safe place for belongings was not standard policy, and the resident was still awaiting reimbursement.
The facility failed to follow proper infection control practices during wound care for two residents. An LPN and a wound care nurse placed clean bandages and gloves on non-clean surfaces and did not change gloves or wash hands appropriately. Additionally, soiled bandages were disposed of in non-biohazard receptacles. The DON expected staff to adhere to proper infection control practices.
The facility failed to notify a resident's POA before transferring the resident to a different facility due to elopement behaviors. The Guardian was informed only after the transfer had occurred, which is a significant deficiency in the facility's handling of the situation.
Failure to Obtain and Administer Prescribed Antibiotic for Active Infection
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer a newly prescribed antibiotic for a resident with active right ankle and foot osteomyelitis and cellulitis of the lower right limb. The resident was admitted with these diagnoses and later seen by podiatry, which prescribed doxycycline on 10/09/2025. According to a PA progress note dated 10/13/2025, the prescription was sent to an out-of-facility pharmacy and was not obtained or initiated by the facility. The PA documented that nursing staff were aware of the prescription and had informed the resident that it had been sent to an outside pharmacy. The PA also documented a discussion with the resident about the need to obtain the medication and that it could be delivered later that day or the following day. Record review of the October 2025 MAR showed the resident did not receive doxycycline from 10/09/2025 through 10/14/2025. The Discharge Transition Plan dated 10/14/2025 did not list doxycycline on the resident’s medication list, and the resident was discharged without documented access to the prescribed antibiotic. In an interview, the resident reported that her foot remained swollen with pus pockets and severe pain and stated she had informed nursing staff that she needed the prescribed antibiotic but did not receive it before discharge. In a subsequent interview, the DON confirmed the resident did not receive doxycycline during this period because the facility never ordered the medication from the out-of-facility pharmacy, despite being aware of the antibiotic order.
Failure to Ensure Dietary Staff Wore Hairnets During Food Preparation
Penalty
Summary
Dietary staff failed to wear hairnets while preparing and serving food in the kitchen, as observed on multiple occasions. One staff member was seen preparing and serving food without a hairnet, and the Kitchen Account Manager also entered the kitchen without wearing a hairnet. During interviews, both the cook and the Kitchen Account Manager acknowledged that hairnets should be worn by all kitchen staff when working in the kitchen. The Administrator confirmed that all staff, not just kitchen staff, are required to wear hairnets when entering the kitchen and crossing the marked yellow line, and that kitchen staff should wear hairnets at all times while working in the kitchen. These actions and inactions resulted in the failure to prepare and serve food under sanitary conditions, affecting all 120 residents listed on the census.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pest infestations within the facility. No additional details regarding specific residents, staff, or observed pests were provided in the report.
Failure to Secure Resident Medical Information on Medication Cart
Penalty
Summary
A nurse was observed leaving the medication cart unattended with the computer screen unlocked and displaying a resident's medical information. The nurse walked away from the cart and entered a resident's room, while other staff and residents were present in the hallway, making the information visible to unauthorized individuals. The unit manager later noticed the open screen, closed it, and reminded the nurse of the expectation to lock or close the screen whenever leaving the cart. The administrator confirmed that the computer screen should not have been left open with resident medical information visible to others. The incident involved a new nurse who was still in training, and the deficiency was identified through direct observation and staff interviews.
Failure to Follow Physician Orders for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident with multiple diagnoses, including Type II diabetes, received care in accordance with professional standards by not following physician orders for diabetic medication management. Record review showed that the resident had specific physician orders for the administration of Insulin Glargine and for the use of Insta-Glucose when blood glucose levels fell below 70 mg/dL. Despite these orders, documentation revealed that on several occasions when the resident's blood glucose was below 70 mg/dL, staff did not administer Insta-Glucose as directed by the physician. Interviews with facility staff, including the DON, Administrator, and nurses, confirmed that the expectation was to administer Insta-Glucose per physician order when the resident's blood sugar was low. However, some nursing staff reported giving other forms of sugar, such as cookies, candy, or juice, instead of following the specific order for Insta-Glucose. The care plan for the resident also indicated monitoring and reporting abnormal blood glucose findings, but the prescribed intervention was not consistently implemented as ordered.
Failure to Enter and Document Nebulizer Treatment Orders
Penalty
Summary
Staff failed to follow physician orders for a resident with multiple serious diagnoses, including COPD, asthma, and cardiomegaly, by not entering an order for an albuterol nebulizer treatment into the medical record. The resident experienced several episodes of hypoxia and shortness of breath, with oxygen saturations dropping as low as 77-88%. Despite telehealth providers documenting the need for nebulizer treatments in their encounter notes on two separate occasions, there was no corresponding physician order entered into the resident's medical record, nor was there documentation that the nebulizer treatment was administered. Nursing progress notes indicated ongoing respiratory distress and confusion, with fluctuating oxygen levels and eventual transfer to the hospital. Interviews with facility leadership confirmed that the expected process of entering all treatment orders into the medical record was not followed, and it was unclear whether the resident actually received the prescribed nebulizer treatments. The lack of documentation and order entry created uncertainty about the care provided during the resident's acute respiratory episodes.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the 300 hall was observed left unlocked and unattended by a nurse who walked away to enter a resident's room, while other residents and staff were present in the area. The cart contained drugs and biologicals that were not secured, making them accessible to unauthorized individuals. The Unit Manager later noticed the unlocked cart, secured it, and reminded the nurse of the expectation to lock the cart whenever it is unattended. The Administrator confirmed that the cart should not have been left unattended and unlocked. This incident had the potential to affect all 25 residents residing on the 300 hall, as identified by the facility's census.
Failure to Provide Menu Choices and Serve Meals as Listed
Penalty
Summary
The facility failed to ensure that the nutritional needs and preferences of all residents were met as required. Staff did not consistently serve food items listed on the posted menu, nor did they provide residents with the opportunity to select their meal choices from the menu or alternate menu in advance of meal service. For example, during a lunch meal service, a resident was served a cubed pork with peppers sandwich instead of the sausage pizza listed on the menu, and the alternate menu option was not provided. The Corporate Chef was unable to explain why the resident received a meal not listed on either the main or alternate menu, speculating it may have been due to a dairy allergy, but could not confirm this or provide a rationale for the substitution. Additionally, residents were not asked in advance about their meal preferences, and substitutions were made without informing them beforehand. One resident reported being served incomplete meals, such as two pieces of toast without any other items, and expressed ongoing dissatisfaction with the food service, stating that repeated complaints to staff had not resulted in changes. The Dietary Manager confirmed that the facility did not have a process for residents to select their meals in advance and that residents were not informed of substitutions prior to meal service, relying instead on residents to request alternate menu items if they did not like what was served.
Uncovered Garbage Dumpster Found Outside Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure all garbage and refuse containers, specifically the outside dumpster used for kitchen and facility waste, were kept covered when not in use. On two separate occasions, the dumpster located outside the back entrance of the kitchen was found to be full of garbage and left uncovered. Interviews with the Maintenance Director confirmed that all facility garbage, including kitchen trash, is disposed of in this dumpster. The Dietary Manager acknowledged that all garbage containers should be closed or covered and stated that it is the kitchen staff's responsibility to ensure this is done, further noting that an open dumpster could attract animals.
Incomplete Infection Surveillance Documentation and Lack of Program Continuity
Penalty
Summary
The facility failed to provide complete documentation of an infection surveillance plan as part of its Infection Prevention and Control Program (IPCP). Record review revealed the IPCP lacked procedures for staff to monitor residents for possible infections and communicable diseases, early detection and management of symptomatic residents requiring laboratory testing, implementation of transmission-based precautions and PPE, and tracking this information in an infectious disease log. Additionally, there was no evidence of an evidence-based surveillance system or data collection tool, nor was there documentation of ongoing analysis of surveillance data or follow-up activities. Interviews with facility leadership indicated a lack of continuity and awareness regarding the IPCP. The Administrator stated that infection surveillance was implemented but could not provide further details. The Interim DON and the Infection Control Preventionist, both new to their roles, reported not receiving any documentation or guidance from the previous DON regarding infection surveillance efforts. The Medical Director was also unaware of his responsibilities in implementing and maintaining an infection surveillance plan and noted that he was only contacted by the facility as needed, without regular meetings or coordination.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive Antibiotic Stewardship Program (ASP) as required by its own policy and regulatory standards. Record review revealed that the facility's ASP policy aimed to reduce inappropriate antibiotic use and prevent antibiotic-resistant organisms, but the Infection Prevention and Control Program (IPCP) lacked essential components. Specifically, there were no written protocols for antibiotic prescribing, including documentation of indication, dosage, and duration. The facility also did not have protocols for reviewing clinical signs, symptoms, and laboratory reports to determine the necessity or adjustment of antibiotics, nor did it identify infection assessment tools. Additionally, there was no process for periodic review of antibiotic use by prescribing practitioners, no protocols to ensure appropriate antibiotic selection, and no system for providing feedback reports on antibiotic use, resistance patterns, or prescribing practices. Interviews with facility leadership, including the Administrator, Interim Director of Nursing (IDON), and Infection Preventionist (IP), confirmed the absence of ongoing monitoring documentation for antibiotic usage patterns and lack of evidence for an annual review of the ASP. The Medical Director (MD) was unaware of his responsibilities regarding the ASP and was not regularly involved in coordinating or monitoring antibiotic use. The Consultant Pharmacist (CP) conducted monthly medication regimen reviews but expected the facility to implement an ASP, indicating he could participate in the program if it were established. These actions and inactions resulted in the facility's failure to ensure a comprehensive and effective ASP, potentially affecting all residents.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Staff failed to maintain a clean, safe, and comfortable environment for residents, as evidenced by multiple observations and interviews. Broken blinds were found in several resident rooms, and the Maintenance Director (MD) acknowledged awareness of some issues but did not routinely inspect all rooms, relying instead on staff to submit work orders. In resident bathrooms, missing wall tiles were observed, and the MD was unaware of these specific deficiencies, again citing a lack of a systematic inspection process. Additionally, several resident rooms had unpainted drywall mud, indicating incomplete repair work, which the MD attributed to being too busy to address. In the dining area, ceiling fans above the eating area had visible dust buildup, and the Housekeeping Staff (HS) could not recall the last cleaning, noting the lack of a regular cleaning schedule. Dining room tablecloths were observed to be stained and odorous, with the HS stating that requests for replacements had not been fulfilled. The tops of vending machines in the common area were dusty and cluttered with trash, and the HS admitted these surfaces were not included in routine cleaning checklists. The conference room, used for resident care plan meetings, had a container of black, odorous water under the sink, which the Administrator confirmed was unacceptable. These findings collectively demonstrate a failure to uphold residents' rights to a safe, clean, and homelike environment.
Failure to Update Care Plans for Utensil Use
Penalty
Summary
Staff failed to update and revise care plans for two residents to reflect their current needs regarding the use of appropriate utensils during mealtime. For one resident with unspecified dementia and muscle weakness, the care plan indicated the use of plastic utensils due to a history of suicidal thoughts, but the resident was observed eating with a metal fork. The Administrator confirmed that the resident was now permitted to use metal utensils, but the care plan had not been updated to reflect this change. Both the Administrator and the DON acknowledged that care plans were not revised as required, despite their expectation for quarterly reviews and updates. For another resident with dementia on a pureed diet due to choking issues, the care plan directed staff to provide a small spoon and specific assistance during meals. However, the resident was observed eating with a regular-sized teaspoon, and the Speech-Language Pathologist stated that the resident managed well with the pureed diet and could use a regular spoon. The Administrator and DON both confirmed that the care plan was not updated to reflect the change in utensil use after the diet modification, and the spoon directive was missed during care plan reviews.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards for all residents by not following facility policies regarding smoking supervision, storage of hazardous items, and staff personal belongings. Specifically, there was conflicting documentation in a resident's smoking assessments regarding the need for supervision, despite the resident having dementia. The Director of Nursing confirmed that residents with dementia were expected to be supervised while smoking, but the assessments were inconsistent. Additionally, observations revealed that lighters were found in multiple resident rooms, contrary to facility policy requiring all smoking supplies to be stored by staff at the nurses' station. Staff interviews confirmed that lighters were sometimes left with residents, and staff were not always successful in retrieving them. Further deficiencies included staff storing personal belongings such as purses and bags in resident rooms, which was against facility expectations and posed potential hazards. Observations also found unsecured bleach cleaning wipes left in a resident bathroom, with the container open and accessible. Staff interviews indicated a lack of awareness regarding the hazards of leaving such items accessible to residents. These actions and inactions placed residents at risk for burns, fire-related injuries, chemical exposure, and ingestion of unsafe substances.
Failure to Discard Opened Insulin Pens Within 28 Days
Penalty
Summary
The facility failed to ensure that nurses and Certified Medication Aides (CMAs) properly labeled and discarded opened insulin pens within 28 days of opening, as required by manufacturer instructions and facility policy. Observations of the medication cart revealed multiple insulin pens for five residents that were opened and dated, but not discarded after 28 days. The facility's Medication Storage Policy required staff to note the date on the label when insulin vials and pens were first used, but did not specifically address discarding insulin pens within 28 days. Manufacturer instructions for Insulin Glargine, Insulin Lispro, and Insulin Aspart all directed that opened vials or pens should be discarded after 28 days, regardless of remaining insulin. Interviews with nursing staff, the unit manager, the Director of Nursing (DON), and the consultant pharmacist confirmed that the expectation was for staff to date insulin pens upon opening and discard them after 28 days. Despite this, the opened insulin pens for five residents were not discarded as required. Physician orders confirmed that these residents were actively receiving insulin therapy. The failure to follow proper labeling and disposal procedures for insulin pens was observed and acknowledged by staff and management during the survey.
Deficient Food Storage, Sanitation, and Meal Service Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices. In the kitchen, there were uncovered, unlabeled, and undated beverages and foods in the walk-in refrigerator, as well as an open box of flour and dirty pitchers stored alongside clean ones. Staff interviews confirmed that these practices were not in line with facility policy. Additional observations revealed a lack of cleanliness, including crumbs in storage bins, dead bug remains on walls, trash on the refrigerator floor, a dirty ice machine, a dirty wash rag stored with clean dishes, a ceiling vent and surrounding area covered in a black substance, crumbs on the dishwasher, and a white dusty substance on canned goods in dry storage. Dietary staff were also observed not wearing required hair nets or beard guards while serving food, despite having hair longer than 1/4 inch. During meal service, staff were seen grabbing resident drinks by the rims of cups with their bare hands and serving them to residents. Interviews with the Dietary Manager confirmed that these actions were not compliant with expected sanitary practices. These deficiencies were identified as potentially affecting all 118 residents in the facility.
Failure to Maintain Accessible and Functional Call Light System
Penalty
Summary
The facility failed to ensure that a working call light system was available and accessible in resident bathrooms and bathing areas, as required by policy. Specifically, two call lights in the 400 hall shower room were found without cords, rendering them nonfunctional. Staff, including CNAs and a nurse, acknowledged that they did not report the broken call lights, despite knowing the importance of doing so. The Unit Manager and Interim Director of Nursing confirmed that staff were expected to report such issues through the TELS maintenance system, to which all staff had access and training. The Maintenance Director stated that he performed monthly checks and had recently inspected the area, but could not provide documentation of repairs for the missing cords. Additionally, a resident with significant mobility impairments and dependence on staff for toileting and dressing was observed on two occasions with their call light on the floor and out of reach. The resident was unable to access the call light to request assistance and expressed a need for help. Staff confirmed the call light was not within reach and were unaware of how long it had been inaccessible. The Unit Manager reiterated that call lights should always be accessible to residents, but this standard was not met in this instance.
Multiple Environmental Safety and Maintenance Deficiencies Identified
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for all 118 residents, as evidenced by multiple deficiencies observed and confirmed through staff interviews. The oxygen storage room door was found to be damaged and warped, allowing it to be easily pulled open, contrary to facility policy and staff expectations that it remain closed and locked due to the presence of oxygen cylinders. During a fire drill, a smoke door on one hall did not close when the fire alarm was activated because the magnetic device holding it open failed to release, despite the Maintenance Director's belief that the issue had been previously fixed. Additionally, a resident's bathroom door frame was observed to have rust along the edges, with flakes falling off when touched, and the Maintenance Director acknowledged being unaware of the issue and recognized the potential for harm. Further deficiencies included the lack of a policy for ceiling tile maintenance, with several ceiling tiles throughout the facility observed to have holes, cracks, or unsealed spaces, particularly around sprinkler heads and ceiling fans. The Maintenance Director stated he only replaced ceiling tiles upon receiving work orders and did not expect staff to submit work orders for certain areas. Electrical safety was also compromised, as a broken and detached electrical outlet in the conference room was in use with a water cooler plugged in, and another outlet in a common area had a cracked and broken faceplate. The Maintenance Director reported that outlet inspections were only conducted in resident rooms and was unaware of the need to inspect outlets in other areas, relying on staff to submit work orders for repairs.
Failure to Accurately Document Advance Directive Status
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was accurately documented in the medical record. Record review showed that the resident's face sheet listed a Do Not Resuscitate (DNR) order, while the New Mexico Medical Orders For Scope of Treatment (MOST) form indicated the resident was a Full Code, meaning they desired lifesaving procedures such as CPR. During an interview, the Unit Manager confirmed that the resident's code status had been changed to Full Code on the MOST form following an audit, but this update was not reflected in the resident's medical records, which continued to show DNR status. This discrepancy in documentation could lead to confusion regarding the resident's wishes for emergency and lifesaving care, as the medical record did not match the most current advance directive indicated on the MOST form.
Inaccurate MDS Assessment for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Record reviews showed inconsistencies between the resident's documented cognitive status and the information coded on two separate MDS assessments. The resident had diagnoses including alcohol use disorder with memory deficits and Alzheimer's disease, with progress notes indicating partial impairment regarding time and mild-to-moderate memory deficits. However, the MDS assessments reflected varying BIMS scores and descriptions of the resident's understanding, with one assessment indicating moderately impaired cognition and another indicating intact cognition, despite no acute change in mental status being documented. Interviews with facility staff revealed further discrepancies. The MDS Coordinator stated that both MDS assessments were correct due to changes in the resident over time but also indicated she was not responsible for the accuracy of the MDS. The Social Services Director, however, acknowledged that one of the MDS assessments was coded incorrectly and contradicted the resident's record, confirming that the resident's ability to understand was not accurately reflected. These actions and inactions led to the deficiency in ensuring an accurate and comprehensive assessment for the resident.
Failure to Label and Date Oxygen Tubing and Humidifier
Penalty
Summary
The facility failed to ensure that oxygen tubing and humidifier bottles for a resident receiving continuous oxygen therapy were properly labeled with the date and staff initials as required by physician orders. Record review showed that the resident had an order for oxygen at 2 liters per minute via nasal cannula, with instructions to change the oxygen tubing weekly and to label each component with the date and initials. During observation, it was noted that the oxygen tubing and humidifier bottle in use for the resident did not have any labeling to indicate when they were last changed or by whom. Interviews with a CNA and the unit manager confirmed that staff did not label or date the oxygen equipment as required, and both acknowledged that labeling should occur on admission and whenever the equipment is replaced.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that two residents received routine dental care as required. One resident did not have visible teeth or dentures and reported that her dentures did not fit properly, expressing a need to be seen by a dentist. Her oral health evaluation indicated she was at risk for oral health and dental care problems, and her last dental appointment was over a year prior. Although there was a physician order for a dental referral, there was no evidence of a follow-up dental appointment for this resident. Another resident was observed with decayed front teeth and stated he had not seen a dentist since before his admission. His records showed he was at risk for oral health and dental care problems, had a care plan noting this risk, and had a physician note documenting bleeding gums. Despite a dental referral order, there was no record of a dental appointment. The unit manager confirmed that both residents had not seen a dentist in the required timeframe and acknowledged issues with finding consistent dental providers.
Failure to Administer Diabetic Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for diabetic medications. Specifically, the staff did not administer Insta-Glucose gel as ordered by the physician when the resident's blood glucose levels fell below 70 mg/dL on multiple occasions. The resident, who was admitted with diagnoses including Type II diabetes mellitus, diabetic neuropathy, and blindness in the left eye, had specific physician orders to receive Insta-Glucose gel if their blood glucose measured below 70 mg/dL. However, the medication administration record indicated that the staff did not follow this order during the month of February 2025, despite documented low blood glucose readings. Interviews with the Unit Manager, Director of Nursing, and nursing staff revealed a lack of adherence to the physician's orders. The Unit Manager and Director of Nursing acknowledged the order for Insta-Glucose gel and stated that staff should follow it. However, Nurse #3 mentioned providing juice or a peanut butter and jelly sandwich instead, while Nurse #4 confirmed that the physician's order should be followed, emphasizing the importance of administering Insta-Glucose gel when the resident's blood sugar was below 70 mg/dL. This discrepancy between the physician's orders and the actions taken by the staff led to the deficiency identified in the report.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated a resident with dignity and respect, as evidenced by an incident involving a resident with multiple complex medical conditions, including quadriplegia, traumatic brain injury, and severe pain due to various spinal issues. The resident, who was cognitively intact, was reportedly left calling out for pain medication for about 30 minutes without adequate response from the staff. During this time, a visitor overheard a staff member yelling at the resident, dismissing her requests by stating that management was busy and the physician was aware of her needs. This interaction was perceived as disrespectful and dismissive of the resident's pain and concerns. Further interviews revealed that the resident felt ignored and was in significant pain, leading her to yell out in frustration. A Certified Nurse Assistant (CNA) confirmed that she had interacted with the resident on the day of the incident and admitted to raising her voice, claiming it was necessary due to the resident's constant yelling. The CNA also acknowledged being confronted by a visitor who felt her behavior was aggressive. This situation highlights a failure in communication and responsiveness to the resident's needs, contributing to the deficiency in maintaining the resident's dignity and respect.
Failure to Report Abuse Allegation to SSA
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency (SSA). The incident involved a resident who had multiple complex medical conditions, including quadriplegia, traumatic brain injury, and neurogenic bladder, among others. On January 8, 2025, two visitors reported to the Social Services Director (SSD) that a Certified Nursing Assistant (CNA) yelled at a resident. The SSD initiated an investigation and suspended the CNA on the same day the allegation was reported. However, the SSD did not report the incident to the SSA, and there was no indication that anyone else did. The Administrator, who also serves as the Abuse Coordinator, was unaware of the incident because she was not present at the facility when it occurred. Although an investigation was conducted, the failure to report the incident to the SSA meant that the necessary corrective measures could not be implemented, and the SSA was unable to ensure the resident's protection from abuse. This oversight highlights a significant deficiency in the facility's reporting procedures for abuse allegations.
Inadequate Pain Management Due to Medication Administration Failures
Penalty
Summary
The facility failed to manage a resident's pain effectively, as evidenced by inconsistent administration of prescribed pain medications. The resident, who had a complex medical history including quadriplegia, traumatic brain injury, and severe spinal conditions, experienced constant pain that affected her sleep and daily activities. Despite having a care plan in place to manage her chronic pain, the resident's pain levels fluctuated significantly, with documented pain scores ranging from 0 to 9 on a 10-point scale. The resident's medication orders included Oxycodone, Tylenol, and Gabapentin, but there were multiple instances where the Oxycodone was not administered as prescribed. On several occasions, the medication was unavailable in the narcotic box, and staff failed to obtain it from the Pyxis machine. Nursing notes indicated that the pharmacy was awaiting a new prescription, but there was a lack of clear documentation explaining the missed doses. This resulted in the resident experiencing unmanaged pain and emotional distress. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed that there was confusion and miscommunication regarding the availability and administration of the Oxycodone. The on-call provider did not initially provide an authorization code to access the medication from the Pyxis, contributing to the delay in pain management. Although other pain medications were administered, the resident did not receive the full regimen of prescribed pain relief, leading to significant discomfort and frustration.
Failure to Provide Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, as evidenced by the lack of a podiatry consult and care despite a physician's order. The resident, who had a history of a right femur fracture, dementia with agitation, mood disturbance, anxiety, neuropathies, and dysphagia, requested to see a podiatrist but refused to allow the nurse to examine her feet. A podiatry consult was ordered, and a wound care evaluation noted extensive toenail growth and swelling in the resident's toes. Despite these findings, there was no documentation of a podiatrist visit, and the resident's toenails remained long and yellow, with the second toe appearing swollen and resting on top of the first toe. Interviews with staff revealed that the resident often wore socks and refused skin checks, which contributed to the lack of awareness of her foot condition. The Unit Manager and a CNA reported that the resident was independent and often refused assistance, including from the podiatrist. The facility's Administrator assumed that the podiatrist had seen the resident, but there was no record of such a visit. The podiatrist had not been to the facility for several months, and the technicians who performed nail care were not podiatrists. This oversight resulted in the resident not receiving the necessary podiatry care as ordered by the physician.
Failure to Document Podiatry Care and Refusals
Penalty
Summary
The facility failed to ensure that medical records were updated with necessary documents and accurate information for two residents reviewed for foot care. For the first resident, the nursing progress notes indicated a request to see a podiatrist, but the resident refused to allow the nurse to examine her feet. A podiatry consult was ordered, but the electronic medical record did not contain documentation that the podiatrist saw the resident or that the resident refused podiatry care. The administrator confirmed the absence of updated podiatry documentation and acknowledged that the staff did not document the resident's refusal of the podiatry visit in the electronic medical record. For the second resident, the most recent podiatry note indicated that the resident was seen by a podiatrist and received specialized nail care, with a recommendation for follow-up every two months. However, the electronic medical record did not contain any podiatry notes or documented refusals after the last visit. The resident stated he had not had an appointment with the podiatrist for at least nine months and managed his own nail care. The administrator explained that the resident frequently refused care, including monthly podiatrist visits, and was now scheduled to see the podiatrist yearly. The administrator confirmed that staff did not document the resident's refusal of the podiatry visit in the electronic medical record.
Staffing Shortages Affect Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of all 116 residents, specifically in offering baths or showers as scheduled. This deficiency was identified through record reviews, observations, and interviews. A Licensed Practical Nurse (LPN) reported that staffing shortages were more prevalent during the night shift, affecting the ability to provide scheduled baths or showers. An anonymous staff member confirmed the facility was understaffed, leading to burnout among staff and frequent missed baths or showers for residents. Registered Nurse (RN) also noted that staffing issues, particularly on weekends, resulted in residents missing their scheduled hygiene care. The Director of Nursing acknowledged the staffing challenges but stated efforts were made to meet residents' needs despite these issues.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for residents on the 400 Unit. During observations, surveyors found three mattresses and an oxygen concentrator placed on the floor against hallway railings near room 401. Additionally, a bedside commode was repeatedly observed outside room 408, against the wall and below the handrail. Interviews with staff, including a Registered Nurse and a Licensed Practical Nurse, confirmed these items should not have been left in the hallway. The Administrator acknowledged that the company collecting mattresses preferred them in a visible spot but agreed that these items should not have remained in the hallway for an extended period.
Deficiencies in Resident Admission and PICC Line Care
Penalty
Summary
The facility failed to meet professional standards of quality care for two residents, identified as R #7 and R #9. For R #7, the facility did not provide timely care or assessment upon admission. The resident arrived at the facility in the evening and was not assessed by a nurse until several hours later, as the admitting nurse was occupied with administering medications to other residents. Additionally, R #7 was not offered hydration or a snack until early the following morning, despite requests from the resident and his sister. Interviews with staff confirmed that the room was not ready upon arrival and that the resident should have been greeted, assessed, and offered refreshments promptly. For R #9, the facility did not obtain necessary physician orders for the care and monitoring of the resident's Peripherally Inserted Central Catheter (PICC) line. The resident was admitted with a PICC line for intravenous antibiotic administration, but the electronic health record did not contain orders for monitoring or dressing changes. The PICC line was not assessed or the dressing changed until the day of the resident's discharge, which was several weeks after admission. Interviews with nursing staff and management confirmed that the PICC line should have been monitored daily and the dressing changed weekly, but these actions were not documented or performed. The deficiencies in care for both residents highlight a lack of adherence to professional standards and protocols for new admissions and ongoing care. The failure to promptly assess and provide necessary care and hydration to R #7, as well as the oversight in managing R #9's PICC line, demonstrate significant lapses in the facility's procedures and staff responsiveness.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for five residents, specifically in the area of bathing and showering. Each resident had a care plan that outlined their need for assistance with ADLs due to various health conditions, such as recent illness, hospitalization, or polytrauma. Despite these documented needs, the facility staff did not consistently offer or provide the scheduled bed baths or showers as required by the residents' care plans. For instance, one resident was scheduled to receive bed baths or showers twice a week but only received them sporadically, leading to feelings of discomfort and dissatisfaction. Another resident, who was dependent on staff for ADL care, was only given one bed bath or shower during their stay, despite multiple requests for more frequent assistance. Interviews with staff, including CNAs and the DON, confirmed that the residents did not refuse the care and that the staff failed to adhere to the scheduled bathing routines. The documentation survey reports further revealed discrepancies between the scheduled and actual provision of bed baths or showers for the residents. In some cases, residents did not receive any bed baths or showers over extended periods, contrary to their care plans. The DON acknowledged the failure to meet the residents' needs for personal hygiene, which was corroborated by interviews with family members and staff who were aware of the residents' unmet requests for assistance with bathing.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for two residents, leading to discrepancies in medication administration documentation. For one resident, the Medication Administration Record (MAR) indicated that a Breyna inhaler was administered on specific dates, despite the resident stating he did not receive it due to increased intraocular pressure. The inhaler was found unused, with the metered dose counter confirming it had not been administered. Interviews with nursing staff revealed a lack of awareness regarding the discrepancy, and the Director of Nursing acknowledged the expectation for staff to document refusals accurately. For another resident, the MAR and Treatment Administration Record (TAR) documented the administration of medications that were not available at the facility. The resident's sister confirmed that no medications were provided during her visit, and a nurse admitted that not all medications were available upon the resident's arrival. The Director of Nursing stated that staff should not document administration if medications are unavailable and should notify a provider in such cases.
Failure to Safeguard Resident's Belongings
Penalty
Summary
The facility failed to safeguard a resident's personal belongings, resulting in the loss of a check valued at $800. The resident, identified as R #2, was admitted to the facility and later reported that a check was missing from her dresser. Upon investigation, it was discovered that the check had been cashed via mobile deposit into a bank account. The Business Office Manager (BOM) confirmed the incident and took steps to address the issue by notifying the facility's bank, filing a fraud claim, and reporting the theft to the police. Interviews conducted with the resident and facility staff revealed that the resident was not offered a secure place to store her belongings until after the theft occurred. The Administrator acknowledged that it was not the facility's policy to provide a safe place for residents' belongings, and such measures were only taken as an exception following the incident. The resident expressed frustration over the lack of reimbursement and the absence of a secure storage option prior to the theft.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for two residents. For the first resident, an LPN placed clean bandages on a non-clean surface, specifically the bedside table, and did not change gloves or perform hand washing after cleaning the wound before applying the clean bandages. For the second resident, the wound care nurse placed clean gloves on the bed and clean bandages on a bedside table that contained food items, both of which are non-clean surfaces. Additionally, the nurse discarded soiled bandages in a non-biohazard receptacle, specifically the resident's bedside trash can. During an interview, the Director of Nursing stated that it was expected for all staff to use proper infection control practices, including changing gloves, washing hands, using clean surfaces, and disposing of soiled bandages in biohazard receptacles.
Failure to Notify POA Before Resident Transfer
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) before transferring the resident to a different facility. The resident, identified as R #5, was admitted to the facility and later exhibited behaviors of elopement, including exiting the building and walking down the street. Despite being placed on one-to-one observation and having a wanderguard applied, the resident managed to leave the facility again. Due to these incidents, the facility staff decided to transfer the resident to another facility with a secured locked unit. However, the transfer was executed without prior notification to the resident's POA. The Guardian for the resident was only informed of the transfer on the same day it occurred, but after the transfer had already been completed. The facility administrator confirmed that the staff did not notify the POA before the transfer, and the Social Services Director realized the oversight only after the resident had left the building. This failure to notify the POA before the transfer could result in the POA not being aware of the resident's location, which is a significant deficiency in the facility's handling of the situation.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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