Casa Del Sol Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 2905 East Missouri Avenue, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325108
- Inspections on file
- 20
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Casa Del Sol Center during CMS and state inspections, most recent first.
The facility failed to honor resident choice regarding both dining location and smoking privileges. On one occasion, all residents who typically ate breakfast in the dining room were required to eat in their rooms after staff told them there was not enough CNA coverage, even though three CNAs were on the day shift and the DON later acknowledged there was no valid reason residents could not have used the dining room. In a separate situation, a resident who had signed a smoking agreement had his smoking privileges revoked and was placed on 1:1 supervision based on a roommate’s report and staff detecting smoke odor, without staff directly observing him smoking in a prohibited area, while the resident denied smoking in the bathroom and expressed a desire to continue smoking.
Two residents with indwelling Foley catheters had care plans indicating catheter use, but no corresponding physician orders were documented in their medical records. Review of the charts showed that, despite the presence of Foley catheters noted in the care plans, the physician order sections contained no entries authorizing or detailing the catheters. In an interview, the UM confirmed that staff had not entered the Foley catheter orders into the records and acknowledged that these orders should have been documented.
A resident’s admission MDS inaccurately documented the presence of a Foley catheter, even though the resident did not have one. During observation, the resident was seen without a Foley catheter, and the UM later confirmed that the MDS entry indicating a Foley catheter was marked in error. This reflects a failure to accurately assess and document the resident’s catheter status on the MDS.
A resident was not transferred to the hospital for several hours after a provider ordered the transfer based on recent lab results. The RN on duty delayed sending the resident, citing an inability to print transfer documents, while an LPN on the same shift reported that the printer had been malfunctioning for some time and that he had not received any related education or discipline. The Unit Manager later found the resident still in the facility the next morning, confirmed the delay in carrying out the provider’s order, and identified that no disciplinary action had been documented for the involved staff.
Surveyors found that a resident with a Foley catheter, care planned for this device, did not have required enhanced barrier precaution signage or PPE (gowns and gloves) available outside the room. During observation, no sign or PPE was present, and in interview the UM confirmed their absence and acknowledged that both were expected for this resident due to the Foley catheter. This deficiency was identified for one of three residents reviewed for Foley catheter-related infection control practices.
Surveyors found that two discharged residents did not have discharge summaries in their medical records. Review of facility documentation confirmed that both residents had been discharged, but no discharge summaries were completed or filed. In an interview, the ADON acknowledged that staff should have completed these discharge summaries and that they were expected to be present in the medical record.
A medication cart was observed unlocked and unattended in a hallway, with no staff present nearby. The unit manager confirmed the cart should have been locked when not attended. This lapse had the potential to impact all residents on the affected hall.
Two residents who use mobility aids were unable to access the outdoor gazebo ramp due to a PVC shower chair being left on the ramp, obstructing passage for both a walker and a wheelchair. The maintenance director confirmed the equipment should not have been placed there and was unsure why it was left on the ramp.
Staff did not follow a physician's order to collect a urinalysis with culture and sensitivity from a resident with multiple medical conditions, including a Foley catheter. Although documentation indicated the sample was collected, there were no lab results, and the unit manager later confirmed the lab never received the sample.
The facility failed to properly store and document medications, with open medications lacking open dates and a loose tablet found in a medication cart. Additionally, temperatures for medication refrigerators were not documented for several days, risking medication efficacy.
The facility failed to provide adequate dining space, affecting 57 residents. Observations showed overcrowding with wheelchairs and walkers, hindering movement and requiring staff to stand while assisting residents. Interviews confirmed these challenges, and the DON acknowledged the need for better flow and seating arrangements during meals.
The facility failed to meet care plan requirements by not including all necessary Interdisciplinary Team members in meetings and not holding meetings within seven days of MDS completion for several residents. Additionally, care plans were not updated with current resident information, such as new diagnoses and treatments, leading to incomplete care planning.
The facility failed to ensure CNAs demonstrated competency in necessary skills to care for residents. Three CNAs did not have documented competency evaluations at hire or routinely after, potentially leading to inadequate care. Personnel files lacked evidence of evaluations, confirmed by interviews with the Nurse Practice Educator and DON.
The facility did not complete annual performance reviews for two CNAs, hired in 2018 and 2019, as confirmed by the Nurse Practice Educator. This oversight could result in undertrained staff and inadequate care.
The facility failed to provide routine dental services for two residents, resulting in one resident losing a tooth and not receiving dental care since admission. Another resident's dental care was neglected, with staff not brushing teeth regularly and no dental visits since admission. The Records Manager relied on residents or families to request dental appointments, leading to inadequate dental care management.
A CNA in an LTC facility failed to perform hand hygiene before assisting multiple residents with eating and drinking, as observed during a dining room inspection. The CNA admitted to not following proper hygiene protocols, which was confirmed by the infection control nurse. This lapse in hygiene practices could expose residents to foodborne illnesses.
A resident was not treated with respect and dignity when CNAs stood over him while assisting with meals instead of sitting at eye level, as expected. The CNAs cited a crowded dining area as the reason for standing, despite knowing the proper protocol.
A facility failed to maintain a homelike environment by not repairing a broken windowsill trim in a resident's room. The resident reported the issue had persisted for months, and an observation confirmed the damage. The Maintenance Director acknowledged the problem, noting it was caused by the resident's bed movement scraping the trim.
A facility failed to complete a comprehensive MDS assessment within the required 14 days after a resident's admission. The resident was admitted, but the assessment was delayed beyond the mandated timeframe. The MDS Coordinator confirmed the delay and acknowledged the requirement for timely completion. This could potentially result in unmet resident preferences and care needs.
A resident admitted to hospice experienced a delay in the completion of their Significant Change MDS assessment, which was not finalized within the required 14-day period. The MDS Coordinator confirmed the delay, which could impact the resident's care and services.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their medical records. One resident's MDS inaccurately documented pain medication and antiplatelet use, another resident's MDS incorrectly recorded a pneumonia diagnosis and anticoagulant use, and a third resident's discharge MDS inaccurately stated the discharge location. These inaccuracies could result in the facility not having an accurate understanding of the residents' needs.
A facility failed to develop a comprehensive care plan for a resident, omitting critical information about a foley catheter and high-risk medications, Eliquis and Lasix. Staff interviews confirmed these omissions, highlighting a lack of individualized planning for the resident's care needs.
A resident with end-stage renal disease did not receive their prescribed Renvela medication on multiple occasions due to delays in reordering and receiving the medication from the pharmacy. Staff interviews confirmed that the medication was not reordered in a timely manner, leading to missed doses and a failure to meet professional standards of care.
A facility failed to provide regular oral hygiene care for a resident who required assistance with activities of daily living (ADL). The resident's sister reported irregular teeth brushing, and a CNA admitted to only occasionally brushing the resident's teeth. Documentation for February 2025 lacked records of oral care, and both the Unit Manager and DON confirmed the expectation for twice-daily brushing, as per the facility's policy.
A resident admitted with pressure ulcers on the sacrum and heels did not receive timely wound care orders, with delays of two to three days in obtaining and implementing treatment. The nursing staff failed to consult the provider for necessary orders, contrary to the facility's expectations, potentially leading to inconsistent interventions and worsening of the ulcers.
A resident with chronic pain in her nose and tongue experienced a delay in receiving prescribed pain management treatment. Despite a recommendation from an ENT specialist to start amitriptyline, the facility did not administer the medication until 16 days after the appointment, resulting in continued unnecessary pain. The delay was confirmed by the unit manager and DON during an interview.
A facility failed to ensure timely documentation of a resident's care by the provider during required visits. The NP did not sign and date progress notes at the time of the visit, and there were delays in sending these notes to the facility. The wound care nurse confirmed that they did not receive the consultant's progress notes on the day of the visit, relying instead on verbal orders.
A resident admitted with multiple diagnoses, including a traumatic subdural hemorrhage and thrombocytopenia, was prescribed Eliquis, an anticoagulant. The facility failed to document the required monitoring for bleeding, as confirmed by staff interviews, leading to incomplete medical records.
The facility failed to provide behavioral health training for one CNA, which could impact care for residents with mental health needs. A review revealed that a CNA did not complete the required training, despite residents with anxiety, schizophrenia, and dementia being present. This deficiency was confirmed by the Nurse Practice Educator.
The facility did not submit the results of investigations into misappropriation of property and an abuse allegation to the State Agency within the required five-day period. In both cases, the follow-up reports were completed but not reported in a timely manner, as confirmed by the administrator.
Failure to Honor Resident Choice for Dining Location and Smoking Privileges
Penalty
Summary
The deficiency involves the facility’s failure to honor resident choice regarding dining location and smoking, as required under resident rights to self-determination. A resident reported that on a specific Saturday, residents were told they could not eat breakfast in the dining room because a CNA had called out, and all residents who normally ate in the dining room were required to eat in their rooms instead. Review of employee timecards for that date showed three CNAs were working the day shift. The DON stated the facility was supposed to have four CNAs but only had three, confirmed that residents had to eat in their rooms and not in the dining room, and acknowledged there was no reason this should have occurred and that residents should have been able to eat breakfast in the dining room. The deficiency also includes the facility’s revocation of a resident’s smoking privileges without staff directly observing a violation of the smoking policy. The resident, who had signed a Smoking Agreement and Procedures form stating that failure to comply with designated locations, times, and rules could result in termination of smoking privileges, reported that his smoking privileges were taken away and that he had been placed on 1:1 care because staff said he was smoking in the bathroom, which he denied. Progress notes documented that his roommate reported he had been smoking in the bathroom and that his smoking privileges were revoked, and later that the ombudsman was notified that the resident was non-compliant with the smoking policy based on the roommate’s report and his frequent exits from the center, and that he was on 1:1 supervision. The Administrator confirmed that smoking privileges were removed because the roommate said the resident was smoking in the bathroom, that staff never caught him but could smell him, that he liked to keep his smoking materials instead of handing them to staff, and that a new smoking agreement and procedure had been implemented after his admission.
Missing Physician Orders for Foley Catheters in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents with indwelling Foley catheters when physician orders for the catheters were not documented in their charts. Record review showed that one resident, admitted on an unspecified date, had a care plan dated 03/03/26 indicating the presence of a Foley catheter, but the physician’s orders contained no documented order for that catheter. Another resident, also admitted on an unspecified date, had a care plan dated 02/09/26 indicating the presence of a Foley catheter, yet the physician’s orders similarly lacked any documented order for the catheter. During an interview on 03/09/26 at 2:28 p.m., the Unit Manager confirmed that staff had not entered Foley catheter orders into the medical records for these two residents and acknowledged that such orders should have been documented.
Inaccurate MDS Documentation of Foley Catheter Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for one resident regarding the presence of a Foley catheter. Record review of the resident’s face sheet showed an admission on an unspecified date, and the admission MDS, dated on an unspecified date, documented that the resident had a Foley catheter. However, during an observation on 03/09/26 at 2:15 p.m., the resident was observed without a Foley catheter in place. In a subsequent interview at 2:28 p.m., the Unit Manager confirmed that the resident did not have a Foley catheter and acknowledged that the MDS incorrectly indicated the presence of a Foley catheter. This inaccurate documentation on the MDS constituted a failure by staff to correctly assess and record the resident’s catheter status, resulting in an MDS that did not reflect the resident’s actual condition.
Failure to Timely Transfer Resident to Hospital After Provider Order
Penalty
Summary
The deficiency involves the facility’s failure to provide timely hospital transfer for a resident after a provider ordered the transfer based on recent lab results. Record review showed that the resident was admitted on an unspecified date and later sent to the hospital on another unspecified date. A 5‑day follow‑up report documented that at approximately 11:00 p.m. on 01/14/26, the resident’s provider ordered that the resident be sent to the hospital due to recent lab findings. However, the resident was not actually sent out until after 6:30 a.m. on 01/15/26. During this period, the RN on duty did not carry out the transfer order, stating that she did not send the resident because she was unable to print the documents needed for transfer to the hospital. Further interviews and record reviews clarified the circumstances around this delay. An LPN working the same night shift reported that the printer had not been working for a while at the beginning of the year and stated that he did not receive any education or disciplinary action related to transferring residents to the hospital. The Unit Manager confirmed that when she arrived at the facility on the morning of 01/15/26, the resident had still not been sent to the hospital despite the provider’s order from the previous night, and that the resident was then sent to the hospital at that time. The Unit Manager also stated that education and disciplinary action regarding sending residents to the hospital had been given verbally to the RN and LPN, but later confirmed, after reviewing their personnel files, that no disciplinary action had actually been documented for either staff member.
Failure to Implement Enhanced Barrier Precautions for Resident With Foley Catheter
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to enhanced barrier precautions for a resident with a Foley catheter. Record review showed the resident was admitted on an unspecified date and had a Foley catheter care plan dated 03/03/26. During an observation on 03/09/26 at 2:15 p.m., surveyors noted that there was no enhanced barrier precaution sign or PPE available outside the resident’s room, despite the resident’s need for such precautions due to the Foley catheter. In a subsequent interview at 2:18 p.m., the Unit Manager confirmed that the enhanced barrier precautions sign and PPE were not in place and stated that she expected staff to have both in place for this resident because of the Foley catheter. The report further notes that this failure to follow proper infection control practices occurred for one of three residents sampled for Foley catheters and that the facility did not provide the required signage and PPE for staff and visitors to use during high-contact care under enhanced barrier precautions. The deficient practice was identified through observation, interview, and record review, and it was specifically linked to the absence of appropriate infection control measures for the resident with a Foley catheter.
Failure to Complete and Maintain Discharge Summaries for Discharged Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide required discharge summaries for two of three sampled residents who were discharged. Record review of the admission/discharge report showed that Resident #1 was discharged on 01/07/26, but the resident’s medical record did not contain a discharge summary. Similarly, nursing progress notes for Resident #2 documented that this resident was discharged on 01/07/26, yet the resident’s medical record also lacked a discharge summary. During an interview on 01/14/26 at 10:12 a.m., the ADON confirmed that both residents did not have discharge summaries and stated that staff should have completed these summaries and that they should be present in the medical record. The deficiency centers on the inaction of facility staff in completing and placing discharge summaries into the medical records for these discharged residents, despite the facility’s expectation, as confirmed by the ADON, that such documentation be completed and maintained.
Unattended Unlocked Medication Cart Found on Resident Hall
Penalty
Summary
Surveyors observed that medications were not properly secured on the 300 hall, as a medication cart was found unlocked and unattended in the hallway. No staff were present in the area at the time of the observation. The unit manager later confirmed that the cart was indeed unlocked and acknowledged that medication carts are required to be locked when unattended. This deficiency had the potential to affect all 14 residents residing on the 300 hall, as identified on the resident census provided by the Administrator.
Obstruction of Gazebo Ramp Limits Mobility Access
Penalty
Summary
The facility failed to provide reasonable accommodation for the mobility needs of two residents who use assistive devices, such as a front wheel walker and a wheelchair, by not ensuring that the ramp to the outdoor gazebo was accessible. One resident reported being unable to use the ramp due to medical equipment, specifically a PVC shower chair, being left on the ramp, making it too narrow for her walker. Another resident, who uses a wheelchair, also stated she could not use the ramp when medical equipment was present. Observations confirmed that the PVC shower chair was repeatedly left at the top of the ramp over multiple days, obstructing access. The maintenance director acknowledged the chair should not have been placed there and was unsure why it was left on the ramp.
Failure to Complete Physician-Ordered Urinalysis
Penalty
Summary
Staff failed to follow a physician's order for a resident who was admitted with multiple diagnoses, including a fracture of the lower end of the left femur, generalized muscle weakness, pain in the left hip, and repeated falls. The physician had ordered a urinalysis with culture and sensitivity to be collected from the resident's Foley catheter, specifically instructing that the sample be collected from the tube and not the collection bag. Documentation on the treatment administration record indicated that the urine sample was collected as ordered. However, a review of the medical record revealed that there were no laboratory results for the urinalysis or culture and sensitivity. During an interview, the unit manager confirmed that there were no results on file and was unaware that the urinalysis had not been collected. Upon contacting the laboratory, it was confirmed that the urine sample was never received for processing.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to properly store medications, as observed during a survey. On the B Unit Medication Cart, lactulose solution and enulose were found open without an open date. Similarly, on the D Unit Medication Cart, a loose white round tablet with no markings was found, and lactulose solution was also open without an open date. These observations indicate a lack of adherence to proper medication labeling and storage protocols. Additionally, the facility did not document temperatures for the medication refrigerators on multiple days. The black medication refrigerator contained insulin, gabapentin, and suppositories, while the white locked medication refrigerator contained bisacodyl suppositories, morphine, and flu vaccines. The absence of temperature documentation for these refrigerators on specific dates was confirmed by CMA #8 and the DON, who acknowledged that medications could spoil if not stored within the appropriate temperature range.
Insufficient Dining Space Affects Resident Safety and Experience
Penalty
Summary
The facility failed to provide sufficient space for dining, which affected the dining experience and safety of all 57 residents. During observations on two separate occasions, the dining area was noted to be overcrowded with residents' wheelchairs and walkers, making it difficult for both residents and staff to move around. This congestion led to incidents such as a resident's wheelchair wheels getting caught on another resident's wheelchair, and staff having to stand while assisting residents with eating due to the lack of space. Interviews with CNAs confirmed the challenges faced during mealtimes, as they often had to stand to assist residents due to the crowded conditions. The DON acknowledged the issue, stating that the expectation is for residents to have an easier flow for getting in and out during meals, and that staff should be seated at eye level with residents to better assess them. The facility was in the process of addressing the space issue to improve the dining experience for residents and staff.
Deficiencies in Care Plan Meetings and Updates
Penalty
Summary
The facility failed to meet care plan requirements for several residents, as evidenced by the absence of required Interdisciplinary Team (IDT) members during care plan meetings for two residents. Specifically, the care plan meetings for these residents did not include all necessary team members, such as therapy, activities, and infection prevention staff, which are crucial for comprehensive care planning. Additionally, the facility did not typically invite Certified Nursing Assistants (CNAs) or providers to these meetings, which could have contributed to incomplete care planning. Furthermore, the facility did not hold care plan meetings within the required seven days following the completion of the Minimum Data Set (MDS) assessments for multiple residents. This delay in scheduling care plan meetings was confirmed by the Social Services Worker, who admitted to being behind in scheduling these meetings. As a result, several residents did not have timely care plan meetings, which are essential for updating and addressing their current health conditions and care needs. Additionally, the facility failed to revise care plans with the most current resident information. For instance, one resident's care plan was not updated to reflect a new diagnosis and treatment for a urinary tract infection, despite having a physician's order for antibiotics. This oversight was confirmed by the MDS coordinator, highlighting a lack of communication and documentation within the facility's care planning process.
Lack of Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) demonstrated competency in skills and techniques necessary to care for residents' needs. Specifically, three CNAs, identified as CNA #8, CNA #9, and CNA #16, did not have documented competency evaluations at the time of hire or routinely after hire. This lack of evaluation could result in CNAs working with residents without adequate knowledge, potentially leading to injury or inappropriate care. The personnel files for CNA #8, CNA #9, and CNA #16 revealed that no competency evaluations were documented to demonstrate their knowledge, ability, and skills to care for residents. Interviews with the Nurse Practice Educator and the Director of Nursing confirmed the absence of these evaluations. The Director of Nursing stated that competency evaluations should be conducted before staff begin working with residents to ensure proficiency in resident care.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct performance reviews at least every 12 months for two certified nursing assistants (CNAs), specifically CNA #10 and CNA #16, out of a sample of three CNAs. This deficiency was identified through interviews and record reviews. CNA #10 was hired on November 14, 2018, and CNA #16 was hired on February 25, 2019. However, there were no performance evaluations found in their employee files. During an interview on March 17, 2025, the Nurse Practice Educator confirmed the absence of performance evaluations for these CNAs. This lack of evaluations could potentially lead to staff being undertrained and providing inadequate care.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that residents received necessary dental services, impacting two residents who were sampled for dental care. Resident #18 reported that a tooth had fallen out approximately a week prior and had not been seen by a dentist since admission. A review of Resident #18's records showed a physician's order for dental consultation as needed, but no dental visit had occurred since admission, as confirmed by the Medical Records staff. Similarly, Resident #23 had not received routine dental care since admission, as noted in the medical records and confirmed by the Records Manager. The resident's sister reported that staff did not regularly brush the resident's teeth, and the resident had not been to the dentist since admission. The Records Manager indicated that dental appointments were made only if the resident requested them or if the family decided care was needed, highlighting a lack of proactive dental care management for residents unable to advocate for themselves.
Failure to Maintain Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain sanitary conditions in food service by not adhering to professional standards of hand hygiene. During an observation in the dining room, it was noted that a CNA did not perform hand hygiene before assisting multiple residents with eating and drinking. This included actions such as cutting sandwiches, moving food on plates, and placing drinks closer to residents. The CNA assisted four residents without performing hand hygiene, except for two instances during the entire meal service. In an interview, the CNA admitted to not performing hand hygiene before assisting each resident, acknowledging that she was supposed to do so. The infection control nurse confirmed that staff were expected to perform hand hygiene prior to assisting residents with eating and drinking. This lack of adherence to hygiene practices could potentially expose residents to foodborne illnesses, although the report does not specify any direct consequences or illnesses resulting from this deficiency.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when staff did not sit next to the resident while assisting with eating. During a lunch observation, CNA #9 stood over the resident instead of sitting beside him, and later asked CNA #16 to assist, who also stood over the resident. Both CNAs confirmed in interviews that they stood over the resident due to the crowded dining area, despite knowing the expectation to sit at eye level with the resident. The Director of Nursing stated that staff should sit down with the resident at eye level during meal assistance.
Failure to Maintain Homelike Environment Due to Broken Windowsill Trim
Penalty
Summary
The facility failed to provide a homelike environment in good condition for a resident by not repairing the trimming on the windowsill in the resident's room. During an interview, the resident pointed out that the trimming on her windowsill had been broken for months, although she could not recall the exact duration. An observation confirmed that a section of the trimming was broken off near the resident's bed. The Maintenance Director acknowledged that the windowsill trim was broken and needed replacement again, attributing the damage to the resident's bed being moved up and down, which scraped the trimming off.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required 14 calendar days after admission for one of the residents reviewed. Specifically, the resident was admitted on a certain date, but the Admission MDS assessment was not completed until January 21, 2025, which exceeded the 14-day requirement. During an interview, the MDS Coordinator confirmed that the assessment was not completed within the mandated timeframe and acknowledged that such assessments should be completed within 14 days of admission. This oversight could potentially result in the resident's preferences and care needs not being adequately addressed.
Delayed MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete and transmit a Significant Change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's condition. Specifically, a resident was admitted to hospice on November 13, 2024, indicating a major change in health status. However, the MDS assessment reflecting this significant change was not completed and signed off by the Registered Nurse until December 19, 2024, exceeding the required 14-day timeframe. During an interview on March 17, 2025, the MDS Coordinator confirmed the delay in completing the Significant Change MDS assessment for the resident following their admission to hospice. This deficiency could likely result in the resident not receiving the appropriate care and services needed due to the delay in updating their care plan.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. For one resident, the MDS inaccurately documented that the resident did not receive scheduled pain medication, despite having an order for pregabalin to treat neuropathy. Additionally, the MDS incorrectly coded clopidogrel, an antiplatelet medication, as an anticoagulant. Another resident's MDS inaccurately recorded a diagnosis of pneumonia, which was not present in the seven days prior to the assessment reference end date, and also incorrectly documented the use of an anticoagulant, despite the resident only being prescribed an antiplatelet medication. A third resident's discharge MDS inaccurately stated that the resident was discharged to a short-term general hospital, while the discharge plan and interviews with staff confirmed that the resident was actually discharged home with their daughter. These inaccuracies in the MDS assessments could result in the facility not having an accurate understanding of the residents' needs, as confirmed by interviews with the MDS coordinator and unit manager.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident, which could result in staff being unaware of the resident's current and actual needs. The resident was admitted with several medical conditions, including a traumatic subdural hemorrhage, acute embolism and thrombosis of the right axillary vein, thrombocytopenia, and neuromuscular dysfunction of the bladder. The resident had orders for a foley catheter change, Lasix for fluid retention, and Eliquis for cerebrovascular accident. However, the care plan did not document the presence of the foley catheter or the high-risk medications Eliquis and Lasix. Interviews with facility staff, including a registered nurse, the MDS coordinator, and the unit manager, confirmed the omissions in the care plan. The staff acknowledged that the resident's care plan should have included the foley catheter and interventions for its care, as well as the high-risk medications. The failure to include these critical elements in the care plan indicates a lack of comprehensive and individualized planning for the resident's care needs.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications according to physician's orders for a resident with end-stage renal disease. The resident was prescribed Renvela, a medication used to control phosphorus levels, to be taken three times a day with meals. However, the medication was not administered on multiple occasions due to it being unavailable. Specifically, the medication was not given on two consecutive days, as documented in the medication administration record and progress notes, which indicated that the facility was awaiting the medication from the pharmacy. Interviews with staff revealed that the medication was not reordered in a timely manner, as it should have been when there were nine pills left. The medication was only reordered on the day it ran out, and it was received the following day late at night. This delay in reordering and receiving the medication resulted in the resident missing several doses, which is a failure to adhere to the physician's orders and maintain the professional standards of care expected in the facility.
Failure to Provide Regular Oral Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required help with oral hygiene. The resident's sister reported that the resident did not have his teeth brushed regularly. A review of the resident's Quarterly Minimum Data Set (MDS) indicated that he was dependent on assistance for ADL care. A Certified Nursing Assistant (CNA) admitted to occasionally brushing the resident's teeth at night but not regularly, and typically only rinsing his mouth. The facility's ADL documentation for February 2025 did not record any oral care being provided. The Unit Manager confirmed that the resident's teeth should be brushed twice daily, as per the facility's oral health policy, but acknowledged the lack of documentation. The Director of Nursing (DON) also stated that the expectation was for residents' teeth to be brushed at least twice a day and documented accordingly. The facility's oral health policy mandates oral hygiene to be performed at least twice daily to maintain oral health and prevent systemic diseases.
Failure to Obtain Timely Wound Care Orders for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely wound care orders and implementation for a resident with pressure ulcers upon admission. The resident was admitted with pressure ulcers on the sacrum and both heels, but wound care orders were not obtained or implemented for the sacrum ulcer until two days after admission and for the heel ulcers until three days after admission. This delay in obtaining and implementing wound care orders could result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of the pressure ulcers. The facility's records revealed that the nursing staff did not consult with the facility provider to obtain wound care orders for the resident's pressure ulcers, which were present upon admission. The facility wound care nurse stated that it is expected for nursing staff to contact the provider to obtain wound care orders upon admission if residents are admitted with pressure ulcers. However, this protocol was not followed, resulting in a delay in the treatment of the resident's pressure ulcers.
Delay in Pain Management for Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident, identified as R #13, who was experiencing chronic pain in her nose and tongue. The resident had been suffering from atypical facial pain, a condition characterized by chronic, constant pain without an apparent cause. During an appointment with an Ear, Nose, and Throat (ENT) specialist on January 29, 2025, it was recommended that the resident be started on amitriptyline, an antidepressant medication often used to treat chronic pain, with a plan to gradually increase the dosage. However, the facility did not implement this treatment plan in a timely manner. The resident's medication order for amitriptyline was not initiated until February 14, 2025, resulting in a 16-day delay from the date of the ENT appointment. This delay in administering the prescribed medication led to the resident continuing to experience unnecessary pain. The deficiency was confirmed during an interview with the unit manager and the Director of Nursing (DON), who acknowledged the delay in starting the prescribed treatment. This oversight in pain management was identified during a review of the resident's records and interviews, highlighting a lapse in the facility's adherence to the prescribed treatment plan for managing the resident's pain.
Deficiency in Timely Documentation of Provider Visits
Penalty
Summary
The facility failed to ensure that a resident's care was properly documented by the provider during required visits. Specifically, the provider did not sign and date progress notes at the time of the visit for a resident who was receiving wound care treatment. The record review revealed that the nurse practitioner (NP) responsible for the resident's care did not sign the progress notes on the day of the visit and delayed sending these notes to the facility. For instance, a note from a visit on February 6 was not signed until February 9 and was not sent to the facility until February 20. Similar delays were noted for subsequent visits, with some notes not being sent to the facility until March 14, despite visits occurring in February and early March. During an interview, the facility's wound care nurse confirmed that they did not receive the wound care consultant's progress notes on the day of the visit. Instead, the nurse relied on verbal orders provided by the consultant during rounds. This practice resulted in a lack of timely written documentation, which is essential for ensuring that the resident's needs are met and that care is appropriately coordinated. The absence of signed and dated progress notes at the time of the visit constitutes a deficiency in the facility's documentation practices.
Incomplete Medical Record Documentation for Anticoagulant Monitoring
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident, which could negatively impact the care provided. The resident in question was admitted with several diagnoses, including a traumatic subdural hemorrhage, acute embolism and thrombosis of the right axillary vein, and thrombocytopenia. A physician's order was in place for the resident to receive Eliquis, an anticoagulant, to manage a cerebrovascular accident. However, the facility did not document the necessary monitoring for bleeding, which is crucial for residents on anticoagulants. Interviews with staff revealed that the facility's protocol requires monitoring for bleeding in residents taking anticoagulants, and this should be documented in the electronic medical record. Despite this requirement, there was no documentation of monitoring for bleeding for the resident from the time of admission until several weeks later. Both a registered nurse and the unit manager confirmed the lack of documentation, acknowledging that the expected monitoring had not been recorded, which constitutes a deficiency in maintaining accurate medical records.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide necessary behavioral health training for one of the three certified nursing assistants (CNA #8) sampled for training. This deficiency was identified through a review of training records and confirmed by the Nurse Practice Educator. The lack of training could potentially impact the care provided to residents with specific mental health needs. The report highlights three residents with mental health diagnoses: one with an anxiety disorder, another with schizophrenia, and a third with dementia, anxiety, and depression. Despite these residents' needs, CNA #8 did not complete the required behavioral health training, which is essential for recognizing and responding to the mental health issues these residents may present with.
Failure to Timely Report Investigation Results of Abuse and Misappropriation
Penalty
Summary
The facility failed to report the results of investigations into misappropriation of resident property and allegations of abuse to the State Agency within the required five-day timeframe. In one instance, a resident reported that $45 was missing from her purse, but the facility did not submit the follow-up report regarding this misappropriation to the State Agency until nearly a month after the initial incident was reported. Documentation confirmed that the investigation was completed, but the required notification was delayed. In a separate case, another resident reported experiencing pain after a staff member performed an improper transfer. The facility completed its investigation within the required period, but the follow-up report to the State Agency was not submitted until almost a month after the incident. In both cases, the administrator confirmed the late submission of the follow-up reports to the State Agency, failing to meet the regulatory requirement for timely reporting.
Latest citations in New Mexico
A clogged floor drain sink in a janitor room led to black, dirty water accumulating in the drain and overflowing into a hallway. A housekeeper reported that the drain, used for disposing of mop water and cleaning chemicals, had been clogged for some time and that she had informed her supervisor. The housekeeping supervisor stated she had submitted several work orders and that housekeeping staff had been attempting to unclog the drain themselves for months, while the maintenance director reported having no active work orders for the issue and indicated that such black water can carry harmful microorganisms. The administrator stated he expects staff to submit work orders and report issues promptly.
Surveyors found that a treatment cart containing drugs and biologicals on two units was left unlocked and unattended, with no staff present. An LPN confirmed the cart belonged to the treatment nurse, who was not on the unit at the time, and acknowledged that it was unlocked. A consultant nurse later stated that treatment carts are required to be locked when not in use.
A resident with impaired cognition had a family member designated as POA with authority over health care and related decisions. The POA, concerned about the resident’s care, repeatedly requested the resident’s medical records but was directed to Medical Records and required to complete written forms, unlike residents who could obtain records via oral request. The POA initially completed the form incorrectly and was told to redo it; the corrected paperwork was not submitted until after the resident’s death, at which point additional documentation was required. Staff, including MR personnel, acknowledged that the POA was authorized to act for the resident and that the resident lacked capacity to request records independently, yet the POA never received the records, resulting in a failure to allow the representative to exercise the resident’s rights.
A resident with impaired cognition and a low BIMS score had a family member designated as POA for health care and related decisions. The POA became concerned about the resident’s care and requested the resident’s medical records but did not receive them. Nursing notes documented the POA’s expressed frustration about still waiting for the records. The Medical Records staff required the POA to complete authorization paperwork twice, stated the first set was completed incorrectly, and reported that corrected paperwork was not returned until after the resident’s death, at which point additional documentation was required. Staff acknowledged that the POA was authorized to act on the resident’s behalf and that, unlike a resident’s own oral request, the POA’s request was not honored without extra paperwork, resulting in the POA never obtaining the records.
A resident’s care plan was not revised to include a family member’s request that a specific housekeeper have no contact with or provide care to the resident in a secure unit, despite the family reporting that this housekeeper had previously caused the resident to fall and had been verbally restricted from working around the resident by prior and current leadership. The housekeeping supervisor and the housekeeper confirmed that the housekeeper no longer worked in the secure unit or with the resident, but the MDS nurse reported she was never informed of this change and therefore did not update the care plan, and the ADON confirmed the care plan lacked this information.
The facility failed to maintain required postings of Ombudsman contact information in accessible areas for residents and their representatives. Surveyor observations found that Ombudsman information was not posted in the facility and that, when present, it was placed on the side of a refrigerator in the Activities Room rather than in a clearly visible location. The Administrator reported that Ombudsman posters had been removed to allow painting and were not re-posted afterward. This deficiency had the potential to affect all residents in the facility, as they and their representatives would not be aware of how to contact the Ombudsman about concerns.
The facility did not maintain the required 18 months of posted nurse staffing records. Surveyors observed that only the current day’s staffing information was posted in the lobby, and during interviews the new DON reported uncertainty about whether historical staffing records were kept. The Administrator later stated that the facility was trying, but unable, to access prior posted staffing information. As a result, residents and the public could not review the required historical nurse staffing data.
The facility did not consistently provide adequate evening and nighttime snacks to residents who requested them. A resident reported that snacks were rarely offered at night and that staff sometimes said none were available. Observation of the nourishment refrigerator showed minimal, often unlabeled items, while CNAs and the Activities Assistant described limited quantities of milk, yogurt, shakes, and sandwiches for multiple residents on each hall. The DM and DON confirmed that snacks were now restricted to those ordered by the RD, with no general snacks left accessible and no staff access to the kitchen at night, resulting in residents without prescribed snacks frequently being told there were not enough snacks and staff occasionally buying snacks themselves.
A resident with a history of cerebral infarction, dementia, and glaucoma did not receive ordered Dorzolamide HCI-Timolol Maleate eye drops after an LPN accidentally discontinued the medication in the system without a physician’s order. The MAR showed the drops were not administered because no active order was available, and nursing documentation later confirmed the facility had discontinued the eye drops without provider authorization. In interviews, the administrator and DON acknowledged that the medication had been stopped in error and that there was no physician order to discontinue it.
A resident with COPD, acute respiratory failure, pulmonary fibrosis, and recent hospitalization for UTI and sepsis returned from the hospital on palliative care with an order for continuous O2 at 2 L/min via nasal cannula. After arrival, staff removed the ambulance’s portable O2 and attempted to use the facility’s O2 concentrators, which were ineffective, while the resident was restless and grabbing at the air. The resident’s daughter reported a period without O2 while staff tried different concentrators and searched for equipment, estimating about 15 minutes before a portable O2 tank was brought back, at which point the NP pronounced the resident deceased. The DON later questioned why a portable O2 tank had not been used when the concentrators failed, and the NP stated the concentrator in use at the time of her assessment was not working properly.
Clogged Janitor Room Floor Drain and Black Water Overflow
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment for all 89 residents when a janitor room floor drain sink on one unit remained clogged and inoperable. During observation of the 400 Unit, water was seen coming from the janitor room into the hallway, and when the door was opened, the floor drain was observed to be filled with approximately 10 inches of black, dirty water. A housekeeper reported that she had spilled water in the hall while dumping her mop bucket into the floor drain sink and had mopped it up, and she confirmed that the drain was clogged and that this sink was used to dispose of cleaning chemicals from mop buckets. The housekeeper stated she had informed her supervisor about the clogged drain, but it had not been fixed and that it had been this way for “a while.” The housekeeping supervisor reported she had made several work orders regarding the janitor room and water overflow and that she and her staff had been unclogging the drain themselves for months. The maintenance director stated that housekeeping is responsible for their department and should notify him if anything is needed, that he had no active work orders regarding water overflow, and that housekeeping should have submitted a work order for the janitor room. He also stated that the black water could carry bacteria, mold, E. coli, salmonella, and possibly Legionella. The administrator stated he expects staff to place work orders and report issues immediately so they can be addressed right away.
Unlocked and Unattended Treatment Cart on Two Units
Penalty
Summary
The deficiency involves the facility’s failure to secure a treatment cart containing drugs and biologicals on the 500 and 600 units, affecting all 27 residents identified on those units by the census list provided by the Administrator on 04/29/26. On 04/29/26 at 8:40 a.m., surveyors observed at the nurses’ station that a treatment cart on the 500/600 unit was left unlocked and unattended, with no staff present. During an interview at 8:44 a.m., an LPN confirmed that the treatment cart was unlocked and identified it as the Treatment Nurse’s cart, noting that the Treatment Nurse was not on the unit at that time. On 04/30/26 at 2:06 p.m., the facility’s consultant nurse stated that treatment carts are supposed to be locked when not in use. The report states that this deficient practice could result in residents obtaining medication not prescribed to them, resulting in adverse side effects. No specific resident medical histories or conditions at the time of the deficiency are described in the report.
Failure to Honor Resident’s POA Request for Medical Records
Penalty
Summary
The facility failed to allow a resident’s designated representative, who held power of attorney (POA), to exercise the resident’s rights by obtaining the resident’s medical records. The resident had impaired cognitive function with a BIMS score of 5 and had formally designated a family member as POA effective 12/24/24, with authority over long‑term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. A nursing progress note documented that the POA approached the ADON and staff, stating she was still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the facility’s process for releasing records created a barrier for the POA, despite staff acknowledging her authority and the resident’s lack of capacity to request records independently. LPN #1 stated that family members requesting medical records had to go to Medical Records (MR). The MR staff confirmed that the POA requested the records and was given paperwork to complete on two occasions; the first form was filled out incorrectly, and the POA was told to redo it. MR reported that the corrected paperwork was not returned until after the resident died, at which point the facility required additional paperwork to release records after death. MR also acknowledged knowing that the POA could act on the resident’s behalf and that, unlike a resident’s oral request, the POA was required to complete written forms. As a result, the POA never obtained the resident’s medical records.
Failure to Provide Resident’s Legal Representative Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with access to the resident’s medical records upon request. The resident had impaired cognitive function, an impaired thought process, and a Brief Interview for Mental Status (BIMS) score of 5, and had designated a family member as Power of Attorney (POA) with authority over long-term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. Nursing progress notes documented that the POA approached the Assistant Director of Nursing and staff, stating they were still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the Medical Records (MR) staff required the POA to complete paperwork to obtain the resident’s medical records, even though MR acknowledged that the POA was legally authorized to act on the resident’s behalf and that the resident did not have the capacity to request records independently. MR reported giving the POA the required forms twice, stating the first set was filled out incorrectly and that the POA needed to complete them again. MR further stated that the POA did not return the corrected paperwork until after the resident’s death, at which point the facility required additional paperwork to release records following a resident’s passing. MR also stated that if a resident personally requested their own medical records, an oral request would be sufficient and no paperwork would be required. Despite the POA’s requests and authority, the POA never received the resident’s medical records. The facility’s policy on determining validity of authorization for release of protected health information required the Medical Records Director to determine whether an authorization was needed for disclosure, but the records were not provided to the POA prior to the resident’s death.
Failure to Update Care Plan With Family’s Restriction on Specific Staff Contact
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect a family member’s request regarding staff contact. Record review showed that the resident’s care plan, last revised on 06/26/25, did not include the family member’s request that a specific housekeeper not have contact with or provide care to the resident in the secure unit. The family member reported that this housekeeper had caused the resident to fall in her room, that the housekeeper was not a CNA in the secure unit, and that the previous Administrator and DON had informed the family member that the housekeeper would no longer work in the secure unit. The family member also stated that this information had been communicated to the current Administrator and DON when they started working at the facility. Interviews with facility staff confirmed that the housekeeper no longer worked in the secure unit and was not to have contact with or provide care to the resident, but this change was not documented in the resident’s care plan. The housekeeping supervisor stated that the housekeeper did not work in the secure unit due to the family member’s wishes. The housekeeper confirmed she no longer worked in the secure unit and was not to be in contact with or care for the resident. The MDS nurse, who is responsible for entering information into residents’ care plans, stated that staff had not informed her of the family member’s request and acknowledged that any changes to a resident’s care should be entered into the care plan. The ADON also confirmed that there was nothing in the care plan reflecting the family member’s wishes and stated that it should have been included.
Failure to Properly Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post the required Ombudsman contact information in areas accessible to residents and their representatives, as required by regulations mandating that names, addresses, and telephone numbers of pertinent State agencies and advocacy groups be posted along with a statement that residents may file a complaint with the State Survey Agency. On 04/29/26 at 9:35 AM, an observation of the facility revealed that staff did not have the Ombudsman information posted. Later that morning at 10:00 AM, an observation of the Activities Room showed that staff had placed an 8.5 x 11-inch paper with Ombudsman information roughly at eye level on the side of a refrigerator, rather than in a more generally visible or designated posting area. On 04/30/26 at 12:47 PM, the Administrator stated in an interview that the facility had taken down the Ombudsman posters in order to paint and confirmed that staff failed to put the Ombudsman posters back up after the painting was completed. This deficiency had the potential to affect all 89 residents identified on the census list provided by the Administrator on 04/29/26, as residents and their representatives would not be aware of how to contact the Ombudsman about concerns they have.
Failure to Maintain 18 Months of Posted Nurse Staffing Records
Penalty
Summary
The facility failed to retain 18 months of records for the daily posted nurse staffing information, affecting all 89 residents as identified on the census list provided by the Administrator on 04/29/26. During an observation of the front lobby at 8:54 AM on 04/29/26, surveyors noted that the current day’s nursing staff information was posted. However, in a subsequent interview at 8:58 AM, the DON, who reported being new to the position, stated she was unsure whether the facility maintained 18 months of the posted nursing staff information. In a later interview on 04/30/26 at 12:47 PM, the Administrator stated that the facility was attempting to obtain access to the historical posted nursing staff information but had been unable to do so. Because the facility did not have 18 months of posted staffing records available, residents or the public would not have access to review the required historical nurse staffing information.
Failure to Provide Adequate Evening and Nighttime Snacks to Residents
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences for evening and nighttime snacks. One resident reported that snacks were not offered very often, especially at night, and that when he asked for a snack he was sometimes told there were none available. Observation of the locked unit nourishment refrigerator showed only one labeled sandwich dated the previous day, along with unlabeled and undated yogurts, sandwich items in a white shopping bag, and two undated and unlabeled metal tumblers. RN staff stated that the snacks in the white shopping bag were intended for all residents who wanted a snack. Multiple CNAs reported that there were not enough snacks at night, noting that the kitchen was locked, and that only a small number of milk cartons, yogurts, supplement shakes, and a few sandwiches were available despite there being about 22 residents per hall. The Dietary Manager stated that snacks were put out three times a day only according to Registered Dietician orders, and that not everyone received a snack; snacks were not left in the refrigerator for residents, and staff could not access the kitchen at night. The DON reported that the kitchen previously put out a lot of snacks but stopped due to waste and cost, and that snacks were now limited to those prescribed by the Registered Dietician. Staff interviews, including CNAs and the Activities Assistant, indicated that residents without prescribed or labeled snacks frequently asked for snacks and were sometimes told there were not enough, leading staff to purchase snacks themselves or use vending machines to meet residents’ requests. These observations and interviews show that residents who wanted or needed snacks, including those with diabetes, did not have consistent access to adequate evening and nighttime snacks.
Unauthorized Discontinuation of Glaucoma Eye Drops
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when an ordered glaucoma eye drop medication for one resident was discontinued without a physician’s authorization. The resident was admitted with diagnoses including cerebral infarction, dementia, and glaucoma. Physician orders showed multiple start dates for Dorzolamide HCI-Timolol Maleate eye drops for both eyes, to be administered in the morning, evening, and at 5:00 a.m., with discontinuation dates entered in the record. Review of the medication administration record for March revealed that the resident did not receive the ordered eye drops because an active order was no longer available. Further review of nursing progress notes documented that the Dorzolamide HCI-Timolol Maleate eye drops had been discontinued by the facility on a specific date without a physician’s order to do so. During interviews, the administrator acknowledged that the eye drops were discontinued by accident and confirmed there was no physician authorization for discontinuation. An LPN reported that she accidentally discontinued the eye drops and did not realize the error for five days, at which point she recognized that the medication had been stopped in error. The DON also stated that the eye drop medication should not have been discontinued by accident because there was no physician order to discontinue it.
Failure to Provide Continuous Oxygen per Physician Orders Due to Equipment Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide continuous oxygen (O2) as ordered for a resident with significant pulmonary conditions. The resident had diagnoses including fracture of the left femur, COPD, acute respiratory failure, and pulmonary fibrosis, and had recently been hospitalized for a UTI and sepsis. Hospital records indicated diagnoses of pulmonary fibrosis, sepsis, and UTI, with a recommendation for palliative care. Upon discharge back to the facility, the physician’s order specified O2 at 2 liters per minute continuously via nasal cannula. Nursing progress notes documented that the resident arrived at the facility on a stretcher wearing 2 liters of O2, was restless and grabbing at the air, and was placed in bed while staff attempted to transition her from the ambulance’s portable O2 to the facility’s O2 concentrator. According to the nursing notes and interviews, the first O2 concentrator was ineffective, and the resident was temporarily placed on a portable O2 tank with a mask. The facility nurse then attempted to use various connectors and obtained another O2 concentrator, which also did not work properly. The resident’s daughter reported that once staff removed the ambulance’s portable O2 and attempted to use the facility concentrator, there was a period during which the resident was not on O2 while staff searched for another concentrator, and that it took approximately 15 minutes for the nurse to return with a portable O2 tank, by which time the nurse practitioner (NP) stated the resident had died and did not need O2. The DON later stated he questioned why a portable O2 tank had not been used when the concentrators were not working to maintain continuous O2 per the physician’s order. The NP confirmed that when she arrived, the resident was on O2 from a facility concentrator that was not working properly and that she did not know how long it had been malfunctioning before the resident’s death.
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