White Sands Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobbs, New Mexico.
- Location
- 5715 North Lovington Highway, Hobbs, New Mexico 88240
- CMS Provider Number
- 325040
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at White Sands Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure medications, including psychotropics, were tied to specific diagnosed conditions and that PRN psychotropic orders were time-limited. One resident with multiple mental health diagnoses was receiving divalproex and quetiapine with indications documented only as “mood stabilizer” and “mood disorder,” which the DON acknowledged were not supported by corresponding diagnoses. Another resident with peripheral vascular disease and extramedullary plasmacytoma was receiving aspirin for “prophylactic measures” and Bactrim DS for “chemotherapy,” despite having no diagnoses matching those indications. A third resident with dementia, anxiety, bipolar disorder, major depressive disorder, and seizure disorder had PRN lorazepam for anxiety and temazepam for insomnia without stop dates or documented rationale for extended PRN use.
The facility failed to accurately complete MDS assessments for two residents by not correctly coding their scheduled medications. One resident had a physician order for daily Aspirin EC 81 mg for pain, but the quarterly MDS documented that the resident did not receive scheduled pain meds, which the MDS coordinator acknowledged was inaccurate. Another resident had a physician order for Depakote 250 mg three times daily for major depressive disorder, yet the quarterly MDS indicated the resident did not receive anticonvulsant meds; the MDS coordinator confirmed Depakote is an anticonvulsant and that this MDS entry was incorrect.
Two residents were admitted with multiple complex diagnoses, including DM2, hyperlipidemia, OSA, post-MI thrombosis, C. diff enterocolitis, depression, anxiety, epilepsy, and urinary retention. For one resident, no baseline care plan was present in the EHR, and for the other, the baseline care plan contained only a date with no clinical information. In both cases, the DON confirmed that the baseline care plans were not completed accurately or within the required 48-hour timeframe.
Staff failed to follow safe food handling and hand hygiene practices during meal service, including a nurse who assisted a resident by hand and then served another resident’s meal without hand hygiene, and multiple staff who touched drink cups by the rims while serving. A CNA assisted a resident with a clothing protector and then served another resident without washing or sanitizing hands, and a hospitality aide touched a resident’s shoulder before serving another resident’s meal without hand hygiene. In an interview, an LVN confirmed that staff are expected to wash or sanitize hands after touching potentially dirty surfaces and that dishes should not be touched by the rims when serving.
Surveyors found that PASARR Level I screens were inaccurately completed for two residents with documented mental health conditions. One resident had generalized anxiety disorder among other diagnoses, yet the PASARR form indicated no suspected mental illness. Another resident had multiple psychiatric diagnoses, including delusional disorder, major depressive disorder, bipolar disorder with psychotic features, OCD, PTSD, and panic disorder, and had recently received inpatient behavioral health treatment, but the PASARR form still documented no diagnosis or suspected mental illness. The DON acknowledged that both PASARR forms were incorrect.
Surveyors found that staff failed to accurately revise and update care plans for two residents. For one resident, the care plan for enhanced barrier precautions and vision interventions contained another resident’s name, as confirmed by the DON. For another resident with bipolar disorder, Alzheimer’s disease, cataracts, generalized anxiety disorder, and insomnia, observation showed a fall mat in use by the bed, but the care plan did not document the fall mat, despite the DON’s statement that such equipment must be included in the care plan.
A resident with COPD and multiple psychiatric and neurologic diagnoses had a physician order for oxygen at 1–3 LPM via nasal cannula using an oxygen concentrator and/or tank, but the order did not specify whether the oxygen was to be administered continuously or PRN. The resident was observed using a portable oxygen concentrator in the activity room, and the DON later confirmed that the order lacked required frequency details. This omission resulted in respiratory care that was not provided in accordance with professional standards.
A resident was found using a quarter-size bed rail on the upper left side of the bed for mobility and repositioning, but record review showed there was no corresponding physician order authorizing bed rail use. During interview, the DON confirmed that no order had been obtained prior to installation, despite requirements to assess safety risks, review risks and benefits, obtain informed consent, and ensure proper installation and maintenance of bed rails.
The facility did not update its daily nurse staffing posting as required, leaving outdated information displayed. An observation found that the posted staffing data, including RN, LPN, CNA hours and resident census, still reflected the previous day. An RN confirmed that the posting had not been updated and acknowledged it should be changed each day. This failure affected the availability of current staffing information for all residents and visitors.
Surveyors found an expired vial of Naloxone 0.4 mg/mL PRN injection stored in the medication refrigerator during an observation of the medication storage room. The DON confirmed the medication was expired and should have been removed and placed in the designated pharmacy return or destruction area. Review of the facility’s Medication Storage and Expiration policy showed staff are required to regularly audit medication storage areas and remove expired medications, but this process was not followed for the Naloxone, creating a potential issue for any resident needing emergency opioid overdose reversal.
Surveyors identified failures in infection prevention and control when a CNA exited a room wearing a gown and gloves instead of doffing PPE before leaving, contrary to the IPC’s stated expectations. In a separate case, a resident admitted with C. diff and a Foley catheter had no EBP signage or PPE available near the room, despite an LVN acknowledging that EBP should have been in place for this resident.
A resident with severe cognitive impairment and a history of trauma was verbally and physically abused by a nurse aide in training, who struck the resident, covered his mouth, mocked, and threatened him during care. The abuse was witnessed by another CNA and substantiated by an audio recording, with documentation confirming the resident's fear and the aide's presence during the incident. The facility failed to protect the resident from abuse, resulting in Immediate Jeopardy.
A CNA witnessed a NAIT cover a resident's mouth, tap their mouth, and tell them to be quiet, but did not report the incident for seven days. The accused NAIT continued working during this time, and the DON was not informed until a week after the event. The delay in reporting the abuse allegation led to Immediate Jeopardy being identified by surveyors.
A nurse aide in training worked for an extended period and completed 99 shifts before obtaining required certification, exceeding the four-month limit for certification. The Human Resources Director confirmed the aide continued to work without timely certification, contrary to facility expectations.
A resident with significant mobility and cognitive impairments, who required total assistance and two-person mechanical lift transfers, was transferred by a CNA without the required second staff member. During the transfer, the resident fell from the lift, sustaining a subarachnoid hemorrhage that required hospital treatment. Documentation and interviews confirmed that facility policy and the resident's care plan, which required two certified staff for such transfers, were not followed.
A resident was given Metoprolol Succinate and Losartan Potassium outside of the prescribed blood pressure parameters, as staff administered these medications even when the resident's blood pressure readings were below the thresholds set by the physician. The DON confirmed this constituted a significant medication error, as the medications were not held or verified with the physician as required.
A treatment cart on a resident hall was observed unlocked and unattended, with no staff present in the area. An RN confirmed the cart should have been locked and secured it upon discovery. The DON also confirmed that all treatment carts are required to be locked when not in use. This situation had the potential to allow unauthorized access to medical supplies and personal health information for all residents in the affected hall.
A document listing residents and their wound care orders was left visible on a treatment cart, exposing personal health information to unauthorized individuals. The DON confirmed that this information should have been protected from view.
The facility did not provide residents with visible information on how to contact the State Survey Agency to file a complaint. Observations showed that signs were not visible inside the facility, and the Resident Council was unaware of their ability to file complaints. Only one sign was found, facing outside, and not accessible to residents.
The facility failed to maintain a clean environment in the memory care unit, as vomit was observed on the dining area floor. An LPN noted it had been there since breakfast and was awaiting cleaning by housekeeping. The DON stated nursing staff should clean bodily fluids promptly, with housekeeping disinfecting afterward. This deficiency potentially affects all 21 residents in the unit.
The facility failed to ensure accurate PASRR assessments for five residents with documented mental health disorders, including major depressive disorder, anxiety disorder, and PTSD. Despite these diagnoses, the PASRR assessments inaccurately indicated no mental illness. The Social Services Director admitted the facility did not verify the assessments' accuracy before admission, potentially affecting the residents' receipt of necessary services.
The facility failed to develop and implement accurate care plans for two residents. One resident's care plan incorrectly included a hearing deficit, while another resident's care plan included splint use without a physician's order, and the splints were not applied as observed. These inaccuracies and implementation failures could lead to staff being unaware of the residents' actual needs.
The facility failed to change oxygen tubing as required for two residents, one with severe dementia and chronic kidney disease, and another with acute respiratory failure and COPD. The tubing for one resident was not changed weekly as expected, and the other resident's tubing was not dated, despite orders for regular changes. These lapses in care put residents at risk of illness.
The facility failed to assess six residents for bed rail safety risks, lacking necessary documentation such as risk assessments, physician orders, and informed consent. Observations showed residents with bed rails installed without proper assessments, posing potential safety risks. The DON confirmed the need for quarterly assessments but could not provide evidence of their completion.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 15.63% error rate. An RN administered medications to a resident without wearing gloves or using a medication cup, using bare hands to handle the pills. The DON confirmed that staff should use gloves and medication cups, and the RN was unsure why he deviated from the usual practice.
Two residents' rights to dignity were compromised when medical assessments were conducted in the dining area during mealtime. A medical provider and an RN interrupted meals to take vital signs and administer medication, actions that were acknowledged by the DON as inappropriate.
A facility failed to maintain sanitary food storage conditions in the memory care unit. An unlabeled and undated pitcher of white liquid, likely milk from breakfast, was found on a tray in the television room, accessible to residents. A NAIT confirmed the pitcher should not have been left there, and breakfast was served earlier that morning.
The facility failed to remove expired medications and improperly stored medications after therapy completion. An expired Ultrasound Gel was found in the medication room, and medications for a resident were not removed after therapy completion. The ADON confirmed these oversights during an interview.
Failure to Ensure Diagnosed Indications and Time-Limited PRN Use for Psychotropic and Other Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure psychotropic and other medications were prescribed and documented as medically necessary to treat specific, diagnosed conditions, and to ensure PRN psychotropic medications were time-limited or had a documented duration. For one resident with multiple mental health diagnoses including unspecified mood disorder, generalized anxiety disorder, major depressive disorder, PTSD, and dementia, the record showed orders for divalproex sodium as a “mood stabilizer” and quetiapine fumarate for “mood disorder.” During interview, the DON confirmed that the stated indications of “mood stabilizer” and “mood disorder” were not supported by corresponding diagnoses in the clinical record and that these indications did not qualify as specific conditions for prescribing these medications, nor were the medications documented as treating specific diagnosed conditions. For another resident with peripheral vascular disease and extramedullary plasmacytoma, the record showed an order for aspirin with the indication “prophylactic measures” and an order for Bactrim DS with the indication “chemotherapy.” The DON confirmed that “prophylactic measures” is not a diagnosis and that the resident did not have a diagnosis for chemotherapy, and that these medications were not documented as treating specific diagnosed conditions. A third resident with dementia, anxiety, bipolar disorder, major depressive disorder, and seizure disorder had PRN orders for lorazepam for anxiety and temazepam for insomnia. The DON confirmed these PRN psychotropic medications did not have stop dates and lacked documentation of a rationale to extend their use beyond an initial limited period. The surveyors concluded these practices failed to prevent the use of unnecessary psychotropic medications and did not comply with requirements for PRN psychotropic orders.
Inaccurate MDS Coding of Scheduled Pain and Anticonvulsant Medications
Penalty
Summary
The facility failed to ensure accurate completion of the federally mandated MDS assessments for two residents, resulting in discrepancies between physician orders and the information recorded on the MDS. For one resident, record review showed a physician’s order dated 08/13/25 for Aspirin EC 81 mg by mouth in the morning for analgesia, yet the resident’s quarterly MDS indicated that the resident did not receive scheduled pain medications; during interview, the MDS Coordinator confirmed this quarterly MDS was inaccurate because the resident does take Aspirin regularly for pain. For another resident, record review showed a physician’s order dated 09/22/23 for Depakote 250 mg by mouth three times daily for major depressive disorder, but the quarterly MDS documented that the resident did not take anticonvulsant medication; the MDS Coordinator confirmed that Depakote is an anticonvulsant and that this quarterly MDS was inaccurate. These findings demonstrate that the facility did not accurately code the residents’ medication regimens on their quarterly MDS assessments, despite existing physician orders and the MDS Coordinator’s acknowledgment that the assessments were incorrect.
Failure to Complete Accurate Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to create accurate baseline care plans containing the minimum healthcare information necessary to properly care for newly admitted residents. For one resident admitted with diagnoses including type 2 diabetes mellitus, hyperlipidemia, and obstructive sleep apnea, record review of the electronic health record showed there was no baseline care plan in place. During an interview, the DON confirmed that there was not a baseline care plan for this resident and acknowledged that this did not meet her expectations. For another resident admitted with multiple diagnoses, including thrombosis of the atrium and ventricle following an acute myocardial infarction, C. difficile enterocolitis, type 2 diabetes mellitus, depression, anxiety, epilepsy, and urinary retention, the baseline care plan was found to be incomplete. The baseline care plan record contained only a date with no additional information documented. In an interview, the DON confirmed that this baseline care plan was not completed accurately and within 48 hours as expected.
Failure to Maintain Hand Hygiene and Sanitary Practices During Meal Service
Penalty
Summary
The deficiency involves failure to follow safe food handling practices and maintain sanitary conditions during meal service. During a lunch observation, a nurse assisted a resident into the dining area by holding her hand and then immediately served another resident’s lunch meal without washing or sanitizing her hands. The same nurse served meals to additional residents and repeatedly touched drink cups by the top of the rim when placing them on the tables. A certified nurse aide assisted a resident with putting on a clothing protector and then proceeded to serve another resident without performing hand hygiene. The business office manager also served meals and touched cups by the top of the rim when placing them on the tables. Additionally, a hospitality aide touched a resident’s shoulder and then served another resident’s lunch meal without washing or sanitizing his hands. During an interview, another nurse confirmed that staff are expected to sanitize or wash their hands after touching dirty surfaces and when handling food items and trays, and that staff should never touch dishes by the rim when serving. The deficient practices were identified as likely to affect all 111 residents in the facility and were cited as failures to ensure food was served under sanitary conditions and in accordance with safe food handling standards.
Inaccurate PASARR Level I Screening for Residents With Mental Illness
Penalty
Summary
The facility failed to ensure accurate completion of PASARR Level I Identification Screens for two residents with documented mental health diagnoses. For one resident, the admission record showed diagnoses including metabolic encephalopathy, generalized anxiety disorder, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. However, the PASARR form dated 08/23/25 indicated that this resident did not have a suspected mental illness diagnosis. During an interview, the DON confirmed that the resident’s generalized anxiety disorder should have been indicated on the PASARR form but was not. For another resident, the admission record listed multiple mental health-related diagnoses, including Alzheimer’s disease, delusional disorders, dementia with agitation and anxiety, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, obsessive compulsive disorder, PTSD, and panic disorder. Hospital discharge paperwork showed this resident had been admitted to and received inpatient care at a behavioral health hospital. Despite these documented conditions, the PASARR form dated 12/18/25 stated that the resident did not have a diagnosis or suspected mental illness. In an interview, the DON confirmed that this PASARR form was not correct and did not meet her expectations.
Failure to Accurately Revise and Update Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to revise and accurately maintain comprehensive care plans for two residents following their assessments. For one resident, review of the care plan dated 02/17/26 showed that focus areas related to enhanced barrier precautions and vision interventions contained another resident’s name instead of the correct resident’s name. During an interview, the DON confirmed that other residents’ names were used in this resident’s care plan. For another resident, record review showed admission with multiple diagnoses, including bipolar disorder, Alzheimer’s disease, age-related nuclear cataracts in both eyes, generalized anxiety disorder, and insomnia. During observation, this resident was seen ambulating in the room with a fall mat on the floor by the bed. However, review of the care plan dated 12/02/25 revealed no indication that a fall mat was in use for this resident. In an interview, the DON stated that any time a resident uses a fall mat it must be included in the care plan and confirmed that this resident’s care plan did not include the fall mat.
Failure to Specify Oxygen Administration Parameters in Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a resident’s oxygen order specified how it was to be administered. The resident was admitted with multiple diagnoses, including dementia, anxiety, bipolar disorder, major depressive disorder, seizure disorder, and COPD. Record review showed a physician’s order dated 02/24/26 for oxygen at 1–3 LPM via nasal cannula using an oxygen concentrator and/or oxygen tank, but the order did not indicate whether the oxygen was to be given continuously or on an as-needed basis. During an observation in the activity room on 03/10/26, the resident was seen wearing a nasal cannula connected to a portable oxygen concentrator. In a subsequent interview on 03/12/26, the DON confirmed that the oxygen order for this resident did not specify the frequency of use, such as as-needed or continuous, and acknowledged that it should have included this information. This lack of specificity in the physician’s order constituted the failure to provide respiratory care according to professional standards for this resident.
Bed Rail Installed Without Required Physician Order
Penalty
Summary
The facility failed to obtain appropriate physician orders prior to installing a bed rail for one resident reviewed for bedrails. The resident was admitted on an unspecified date, and record review of the physician orders showed no order for the use of bedrails. During an observation and interview in the resident’s room, surveyors noted a quarter-size bedrail on the upper left side of the bed, and the resident confirmed he uses the side rail for mobility and to reposition himself. In a subsequent interview, the DON confirmed that the resident did not have physician orders for the use of bedrails and acknowledged that such orders should be in place prior to installation. This deficiency occurred despite regulatory expectations that, before using a bed rail, the facility should assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bed rail.
Failure to Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post required nurse staffing information daily at the beginning of each shift, including the facility name, current date, total number and actual hours worked by RNs, LPNs, CNAs directly responsible for resident care per shift, and the resident census. On 03/09/26 at 10:01 a.m., an observation showed that the staffing data posting was still dated 03/08/26 and had not been updated for the current day. During an interview at 10:07 a.m. on the same day, an RN confirmed that the posted staffing information was dated for the previous day and acknowledged that it should be updated daily but was not. This deficient practice had the potential to affect all 111 residents, as identified by the Administrator’s census on 03/08/26, by not having current staffing information readily available to residents and visitors. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing information posting requirements and the failure to update the daily staffing data as required.
Expired Naloxone Found in Medication Storage Room
Penalty
Summary
Surveyors identified a deficiency in medication management when an observation of the medication storage room revealed a vial of Naloxone 0.4 mg/mL, 1 mL PRN injection stored in the medication refrigerator with a manufacturer’s expiration date of 12/2025, which facility staff considered expired. During an interview, the DON confirmed that the Naloxone vial was expired and acknowledged it should have been removed from the refrigerator and placed in the designated pharmacy return or destruction area. Review of the facility’s Medication Storage and Expiration policy, revised 09/2010, showed that staff are required to audit medication storage areas regularly and remove any medications that have reached their expiration date, indicating that this required auditing and removal process was not effectively carried out for this medication. This deficient practice was cited as having the potential to affect any resident requiring emergency opioid overdose reversal by providing a medication with potentially reduced efficacy.
Failure to Maintain Proper PPE Use and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices, specifically related to PPE use and Enhanced Barrier Precautions (EBP). During observation of the 300 hall, a CNA was seen exiting a resident’s room while still wearing a gown and gloves. In a subsequent interview, the CNA acknowledged that she was required to remove PPE before leaving the room and confirmed she did not follow this requirement. The Infection Prevention Coordinator stated that staff are expected to don PPE before entering a room and doff it before exiting, and that new PPE should be used each time staff re-enter a room to provide care. The facility also failed to implement EBP measures for a resident with specific infection risks. An observation showed there was no EBP signage or PPE available near this resident’s door or room. Record review revealed the resident had been admitted with enterocolitis due to Clostridium difficile and urinary retention. During an interview and observation, the resident confirmed admission with a C. diff diagnosis and the presence of a Foley catheter. An LVN confirmed that EBP should have been in place due to the resident’s current use of a catheter and diagnosis of C. diff, but these measures were not evident near the resident’s room.
Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, dementia, anxiety disorder, legal blindness, and cerebrovascular disease was subjected to verbal and physical abuse by a nurse aide in training during care. The resident was fully dependent on staff for emotional, intellectual, physical, and social needs, and had a self-care deficit related to activities of daily living. The abuse included the aide striking the resident on the mouth, telling him to hush, covering his mouth with her hand, aggressively placing him in a sit-to-stand machine, and instructing him to urinate in his brief. These actions were witnessed by another certified nursing assistant, who provided both a written statement and an audio recording of the incident. The audio recording captured the aide yelling at the resident to hush and shut up, mocking him, making threatening statements, and giving harsh instructions. The aide admitted to telling the resident to hush and to playfully tapping him, but denied hitting him. Documentation also indicated that the resident expressed fear of a staff member, though he was unable to recall the specific incident during a later interview. The resident's trauma-informed assessment revealed a history of childhood trauma, ongoing feelings of fear and helplessness, and a tendency to try to forget past traumatic events. The incident was reported to facility leadership, and the aide's timecards confirmed her presence during the dates in question. The facility's documentation included witness statements, progress notes, and the audio recording, all substantiating the occurrence of abuse. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident from abuse, resulting in likely emotional distress and trauma.
Removal Plan
- R #4 was assessed by using a Trauma Informed Assessment. No immediate concerns noted.
- Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.
- Safe survey for all facility residents were initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe.
- Referral for additional spiritual services for support within the community for R #4 via hospice team.
- R #4's Care Plan updated for trauma-informed care.
- All staff were re-educated on: Abuse and neglect definition, signs and symptoms of abuse and reporting and when to report; Zero-tolerance expectation; Resident rights; Mandatory reporting within 2 hours.
- Staff training was conducted for all facility staff.
Failure to Timely Report Alleged Abuse and Remove Accused Staff
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe. A Certified Nurse Aide (CNA) witnessed a Nurse Aide in Training (NAIT) cover a resident's mouth with her hand, tap the resident's mouth, and tell the resident to "shut up." This incident occurred on 08/22/25, but was not reported to facility management until 08/29/25, seven days later. During this period, the accused NAIT continued to work in the unit, potentially exposing other residents to risk. The CNA who witnessed the incident did not immediately report it, stating she was unsure of what to do, and only informed a Registered Nurse (RN) after several days had passed. The RN, upon learning of the incident, immediately reported it to the Unit Manager, who then notified the Director of Nursing (DON). The DON confirmed that the facility did not become aware of the allegation until seven days after the event and that the initial report to the State Agency was also delayed. Timesheet records confirmed that the accused NAIT continued to work during the period between the incident and the report. The delay in reporting resulted in the identification of Immediate Jeopardy by surveyors.
Removal Plan
- R #4 was assessed by using a Trauma Informed Assessment.
- Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.
- Safe survey for all facility residents was initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe.
- Referral for additional spiritual services for support within the community for R #4 via hospice team.
- R #4's Care Plan updated for trauma-informed care.
- All staff were re-educated on abuse and neglect definition, signs and symptoms of abuse and reporting and when to report, zero-tolerance expectation, resident rights, and mandatory reporting within 2 hours.
- Staff training was conducted for all facility staff.
Failure to Ensure Timely Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide in training completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of employment. Record review showed that one nurse aide was hired and began working as a nurse aide in training, but did not receive certification until more than six months after starting, during which time the aide worked a total of 99 shifts. The Human Resources Director confirmed that the aide received certification late and continued to work during this period, contrary to the facility's expectation that all nurse aides become certified within four months.
Failure to Use Required Two-Person Assistance During Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow established protocols for safe resident transfers, resulting in a fall and serious injury. A resident with multiple diagnoses, including Alzheimer's disease, repeated falls, Parkinson's disease, and muscle weakness, required total assistance for transfers and was care planned to be transferred using a mechanical lift with two staff members. Despite this, a Certified Nursing Aide (CNA) attempted to transfer the resident alone using a mechanical lift, while a Hospitality Aide was present in the room only for one-to-one monitoring and did not assist with the transfer. During the transfer, the resident fell from the lift after a snapping or popping sound was heard, striking his legs and head on the lift and floor. The incident resulted in the resident sustaining a subarachnoid hemorrhage, as confirmed by a CT scan, necessitating transfer to a hospital for higher-level neurological care. Documentation and witness statements confirmed that the CNA did not obtain assistance as required by the resident's care plan and facility policy, which mandates two certified staff for mechanical lift transfers. The resident was later readmitted to the facility after hospital treatment and resolution of the hemorrhage.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
Staff failed to administer medications according to physician's orders for one resident. The physician's orders specified that Metoprolol Succinate ER 50 mg should be given once daily for hypertension, but held if the systolic blood pressure (SBP) was less than 120, diastolic blood pressure (DBP) was less than 80, or heart rate (HR) was less than 60. Losartan Potassium 100 mg was also ordered once daily for hypertension, to be held if SBP was less than 120. Despite these parameters, the Medication Administration Record (MAR) showed that both medications were administered on multiple occasions when the resident's SBP was less than 120 or DBP was less than 80, contrary to the physician's instructions. The Director of Nursing (DON) confirmed during an interview that the resident received Metoprolol Succinate and Losartan Potassium outside the prescribed parameters, constituting a significant medication error. The DON stated that the expectation is for nurses to follow the orders as written, hold the medication when indicated, and call the physician to verify instructions. The documentation and interview confirm that the medications were not administered in accordance with the physician's orders, resulting in a deficiency.
Unattended Unlocked Treatment Cart on Resident Hall
Penalty
Summary
A treatment cart located in the 200 hall was found unlocked and unattended during a random observation, with no facility employees present in the area at the time. This was confirmed by a registered nurse, who acknowledged that the cart should have been locked and proceeded to secure it. The Director of Nursing also confirmed in a subsequent interview that all treatment carts are required to be locked when not in use. The unlocked cart had the potential to allow unauthorized access to medical supplies and personal health information for all 27 residents in the affected hall. No specific information about the medical history or condition of the residents involved was provided in the report.
Resident Health Information Left Unsecured on Treatment Cart
Penalty
Summary
A deficiency occurred when a paper document containing the names of residents and their wound care orders was left face up on top of a treatment cart, making personal health information visible and accessible to unauthorized individuals. This was observed during a random facility check and had the potential to affect all 27 residents residing in the rooms on the 200 hall. During an interview, the DON confirmed that such information should be safeguarded and not left in plain view.
Lack of Visible Complaint Filing Information for Residents
Penalty
Summary
The facility failed to ensure that residents received information on how to contact the State Survey Agency to file a complaint. During a random observation, it was noted that signs or posters regarding filing a complaint with the state survey agency were not visible throughout the facility. An interview with the Resident Council revealed that they were unaware of their ability to contact the State Survey Agency to file a complaint. Further observation with the Administrator confirmed that only one sign was present, which was located on the front entrance door facing outside, and not visible to residents inside the facility. The sign was printed on a small piece of paper and was not easily accessible or visible to residents within the facility.
Failure to Maintain Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the memory care unit, as evidenced by the presence of vomit on the floor in the dining area. This was observed on 01/06/25 at 9:10 am, near the door leading outside. During an interview, an LPN stated that the vomit had been present since breakfast and that housekeeping staff had been informed, but they indicated it would be cleaned later. The Director of Nursing later stated that nursing staff are expected to clean up bodily fluids such as vomit as soon as possible, with housekeeping responsible for disinfecting the area afterward. This deficiency potentially affects all 21 residents in the memory care unit, as identified by the census provided by the Administrator on 01/05/25.
Inaccurate PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessments for five residents, which is a critical process to prevent inappropriate placement in nursing homes for long-term care. The residents involved had documented diagnoses of mental health disorders, including major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar disorder, mood disorder, and post-traumatic stress disorder. Despite these diagnoses, the PASRR assessments for these residents inaccurately documented that they did not have a diagnosis or suspected mental illness. The Social Services Director acknowledged during an interview that the facility did not verify the accuracy of the PASRR Level 1 assessments for these residents before their admission. This oversight in the assessment process is likely to result in the residents not receiving the necessary services tailored to their mental health needs, as the PASRR process is designed to ensure appropriate placement and care for individuals with mental disorders or intellectual disabilities.
Inaccurate Care Plans and Implementation Failures
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for two residents, leading to potential unawareness of their actual needs by the staff. For one resident, the care plan inaccurately included a communication problem related to a hearing deficit, despite the resident having no such diagnosis. The resident's Minimum Data Set (MDS) indicated adequate hearing without the use of a hearing aid, and during an interview, the resident confirmed no hearing issues. The facility administrator acknowledged the care plan's inaccuracy, emphasizing the expectation for care plans to reflect residents' needs accurately. Another resident's care plan included interventions for wearing bilateral resting hand splints and elbow extension splints, yet there was no physician order for these splints. The resident's mother reported that the splints were not being used during her visits, despite her complaints to the facility. Observations confirmed the resident was not wearing the splints on multiple occasions. This discrepancy between the care plan and actual practice highlights a failure in implementing the prescribed interventions, potentially affecting the resident's care and comfort.
Failure to Change Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents, leading to a deficiency in the care provided. For one resident, who was dependent on supplemental oxygen and had multiple diagnoses including severe dementia and chronic kidney disease, the oxygen tubing was not changed as required. The tubing was last dated 12/22/24, and staff confirmed it should have been changed weekly, but it was not done on 12/29/24. Additionally, there was no medical order for the use of oxygen or care of the equipment for this resident. Another resident, with acute respiratory failure and COPD, also experienced a lapse in care. The oxygen tubing for this resident was not dated, despite a medical order requiring the tubing to be changed every four weeks. Staff confirmed the tubing should have been changed weekly and dated accordingly, but this was not done. These failures in changing and dating the oxygen tubing put residents at risk of becoming ill due to improper respiratory care.
Failure to Assess Bed Rail Safety Risks
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the risk of entrapment in bed rails, which is a significant safety concern. Six residents were identified as having bed rails installed without the necessary assessments, physician orders, or informed consent. Observations revealed that these residents had bilateral quarter side rails in place, yet their medical records lacked documentation of risk assessments, discussions of risks and benefits with the residents or their representatives, and consent forms. Additionally, there was no evidence that the bed dimensions were appropriate for the residents' size and weight. For Resident #23, the care plan indicated the use of bed rails for mobility and positioning, but the comprehensive Minimum Data Set (MDS) did not reflect this usage. Similarly, Resident #25's care plan did not document the use of bed rails, and the admission MDS also failed to indicate their use. Resident #55's care plan and quarterly MDS did not document the use of bed rails, and the same lack of documentation was found for Residents #65, #95, and #98. The Director of Nursing (DON) confirmed that bed rail assessments should be conducted quarterly, but there was no evidence of such assessments being completed for these residents. The absence of proper assessments and documentation for the use of bed rails poses a potential risk of serious injury due to entrapment. The facility's failure to follow protocols for assessing and documenting the use of bed rails indicates a significant oversight in ensuring resident safety. The DON acknowledged the requirement for quarterly assessments but was unable to provide evidence that these assessments had been conducted for the affected residents prior to the survey observations.
Medication Administration Error Due to Improper Handling
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a rate of 15.63%. During a medication administration observation, a registered nurse (RN) administered medications to a resident without wearing gloves or using a medication cup. The RN used his bare hands to open medication bottles and poured the pills directly into his hand before administering them to the resident. This practice was contrary to the facility's protocol, as confirmed by the Director of Nursing, who stated that staff should wear gloves and use medication cups when preparing and administering medications. The RN admitted to normally using the cap of the medication bottle and a pill cup but was unsure why he deviated from this practice during the observed incident.
Violation of Resident Dignity During Mealtime
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect by conducting medical assessments in the dining area during mealtime. This was observed in two instances involving two residents. The first resident, who has severe cognitive impairment and multiple medical conditions including type 2 diabetes, malnutrition, and severe dementia, was approached by a medical provider during lunch. The provider took the resident's vital signs in the presence of other residents and staff, interrupting his meal. In another instance, a registered nurse interrupted a second resident's breakfast to take her vital signs and administer medication in the dining room. The nurse admitted to normally performing such tasks in the privacy of residents' rooms but was in a hurry on this occasion. The Director of Nursing confirmed that medical assessments should not be conducted during mealtimes or in communal areas when others are present.
Unsanitary Food Storage in Memory Care Unit
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in the memory care unit. During an observation, a pitcher of white liquid, which was neither labeled nor dated, was found on a tray in the television room of the memory care unit. This area was accessible to residents, including two identified residents. The Nurse Aide in Training (NAIT) confirmed that the pitcher should not have been left there and speculated that it contained milk from breakfast. The facility's records indicated that breakfast was served from 7:30 am to 9:00 am, suggesting the pitcher had been left out for over an hour.
Expired Medications and Improper Storage of Completed Therapy Medications
Penalty
Summary
The facility failed to ensure that medications and medical supplies were not expired and that medications were properly destroyed after completion of therapy. During an observation and interview with the Assistant Director of Nursing (ADON) in the medication room on the Skilled Care Unit, an expired Ultrasound Gel was found on top of the refrigerator by the bladder scanner. The ADON confirmed the expiration and stated that expired medications and supplies should be removed from the medication storage room and medication carts on or before the expiration date. Additionally, the facility did not remove medications for a resident after the completion of therapy. A review of the resident's medical orders revealed an order to administer ceftriaxone with lidocaine for three days. However, two unused bottles of ceftriaxone and two bottles of lidocaine were found in the medication storage room after the order was completed. The ADON acknowledged that the medications should have been removed as soon as the order was completed, but staff failed to do so.
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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