Casa Maria Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Roswell, New Mexico.
- Location
- 1601 South Main Street, Roswell, New Mexico 88203
- CMS Provider Number
- 325086
- Inspections on file
- 26
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Casa Maria Healthcare during CMS and state inspections, most recent first.
A resident with multiple comorbidities and moderate cognitive impairment reported that a CNA took her phone without permission and used a payment app to transfer $100.00 from the resident’s account to the CNA’s personal account. The resident discovered the missing funds upon reviewing a bank statement, and the Administrator later confirmed through investigation that the CNA had misappropriated the resident’s money.
The facility did not update and post required daily nurse staffing information at the start of each shift, including the current date, RN, LPN, and CNA staffing numbers and hours worked, and the resident census. A posted staffing sheet observed on a survey date was several days old, and an admissions staff member confirmed it had not been updated daily, potentially affecting all 96 residents and limiting access to current staffing information for residents and visitors.
Surveyors found that the facility failed to maintain safe medication storage when expired Novolog Mix 70/30 Flex Pens were discovered in a medical supply storage refrigerator. One insulin pen had an expiration date in early 2024 and three additional pens had mid-2025 expiration dates, yet all remained stored with other medical supplies. An LPN confirmed the insulin pens were expired and should have been disposed of, and this deficiency was determined to have the potential to affect all residents in the facility.
The facility failed to perform regular inspections and maintenance of bed frames, mattresses, and bed rails for multiple residents, as required to identify possible entrapment areas and ensure that bed components were safely attached. During interviews, the DON and the Administrator confirmed that bed evaluations, assessments, and routine maintenance had not been completed as expected and acknowledged that this did not meet their own safety expectations.
Surveyors found that the facility administered psychotropic medications without ensuring appropriate diagnoses or regulatory-compliant orders. One resident received PRN lorazepam for anxiety and restlessness under an order that was not time-limited to 14 days and did not specify duration, and this resident did not have an anxiety diagnosis. Another resident received scheduled olanzapine for “mood” and trazodone for insomnia, even though “mood” was not an appropriate indication and the resident did not have an insomnia diagnosis. The DON confirmed these discrepancies and acknowledged that psychotropic medications should be linked to proper indications and that PRN psychotropics must be time-limited or have a defined duration.
Surveyors found that the facility did not complete accurate baseline care plans within 48 hours of admission for several residents. One resident with multiple fractures and mood disorders had a baseline care plan that was not finalized until nearly two weeks after admission. Another resident with a sacral fracture, HTN, osteoarthritis, and urinary retention had a care plan that was not fully signed by all disciplines until more than two weeks after admission. A third resident with complex conditions including hip fracture, chronic respiratory failure, vertebral fractures, gastrostomy, history of cancer treatment, and long-term anticoagulant use had a baseline care plan that failed to document current smoking, anticoagulant therapy, and any nutritional information despite MDS documentation and observation of a feeding tube and pump. The DON acknowledged that these baseline care plans did not meet her expectations.
The facility failed to keep care plans current for several residents using bed rails and requiring assistance with bed mobility. One resident with morbid obesity, muscle weakness, and lack of coordination had quarter bed rails in use and reported using them for positioning, but the care plan and EHR contained no bed rail interventions or orders. Another resident with major depressive disorder, insomnia, anxiety, hyperlipidemia, and heart failure had a physician order for quarter bed rails for mobility and transfers and bed rails in place, yet the care plan lacked any bed rail interventions. A third resident with multiple conditions including ESRD, anemia, muscle weakness, and systolic CHF was documented on the MDS as dependent on staff for bed mobility and was observed unable to reposition without assistance, but the care plan still stated the resident could reposition independently. A fourth resident with a history of falls, lack of coordination, depression, and chronic systolic CHF was observed with bed rails in use, but the care plan was not updated to include quarter bed rails for mobility and transfers until later, as confirmed by the DON.
Surveyors found that multiple residents were using quarter-size bed rails for mobility, positioning, and transfers without the facility completing required processes. Bed rails were observed in use on both sides of several beds, but medical records frequently lacked physician orders, entrapment risk assessments, documentation of risk/benefit discussions, and informed consent. In some cases, care plans and MDS assessments did not reflect actual bed rail use, or bed rail interventions were added only after use had already begun. Residents and a representative reported using the rails for assistance, while the ADM and DON acknowledged that appropriate assessments, orders, education, and consents for bed rail use had not been completed.
Surveyors found that three residents were receiving medications whose indications did not match their current diagnoses. One resident with insomnia, major depressive disorder, and a psychotic disorder was routinely given cetirizine for seasonal allergies and acetaminophen and tramadol for pain, despite not having allergy or pain diagnoses. Another resident with schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety was administered weekly methotrexate ordered for rheumatoid arthritis, although no RA diagnosis was present. A third resident with major depressive disorder, insomnia, anxiety, hyperlipidemia, and heart failure received daily Zyrtec via G-tube for allergies without an allergy diagnosis. In each case, the DON confirmed that the indications for these medications did not correspond to the residents’ documented conditions or related symptoms.
Surveyors found that the facility failed to maintain sanitary food storage, kitchen conditions, and food service practices. The ice and water machine and multiple kitchen areas were visibly soiled with dried food particles, liquids, and overflowing trash. In a satellite kitchen refrigerator, expired dairy products, old leftovers, and multiple food items were stored without labels or dates, and a refrigerator temperature log had not been updated for an extended period. A dietary aide confirmed that items should have been labeled, dated, and discarded after three days but were not. Additionally, a resident was observed removing another resident’s food from a tray cart, having another resident ask staff to heat it, and a CNA reheated and served this food, later admitting this violated sanitary practices.
Surveyors found that the facility did not consistently implement Enhanced Barrier Precautions (EBP) for three residents who had conditions such as multiple pressure ulcers, a G-tube for enteral feeding, and a Foley catheter. During observations, EBP signage was missing at the entrances of these residents’ rooms, even though PPE was available in some cases. A CNA confirmed the absence of required EBP signage for one resident, and the DON acknowledged that residents with open wounds or indwelling devices are expected to have EBP signs posted outside their rooms with PPE available for staff.
A resident with documented preferences for activities such as current events, educational programs, movies, sports, and television was unable to watch TV after staff removed the power strip that allowed her television to reach the room outlet, citing safety concerns. The facility’s electrical safety policy outlined conditions for safe power strip use, but after removal, no alternative means were provided to maintain the resident’s access to television, despite her expressed upset and the care-planned preference for this activity.
Surveyors found that multiple residents had conflicting advance directive information across their medical records. In several cases, signed MOST forms indicating DNR status did not match the EHR face sheet, physician orders, or care plans, which documented Full Code/CPR or omitted code status entirely. The DON confirmed during interviews that the documentation for these residents was inconsistent and did not meet expectations that all advance directive information match throughout the chart.
Surveyors found that the facility failed to complete accurate and timely baseline care plans for four newly admitted residents. One resident with metabolic encephalopathy and end-stage renal disease had missing Social Services, Rehab, and Activities information and an incorrect regular diet order. Another resident with multiple fractures and mental health diagnoses had a baseline care plan that was not completed until nearly two weeks after admission. A third resident with a sacral fracture, HTN, osteoarthritis, and urinary retention had a baseline care plan finalized more than two weeks post-admission. A fourth resident with complex conditions, including chronic respiratory failure, vertebral fractures, gastrostomy status, and long-term anticoagulant use, had a baseline care plan that omitted current smoking status, anticoagulant therapy, and all nutritional information despite use of a feeding tube.
Surveyors found that staff exceeded the acceptable 5% medication error rate when an LVN crushed and combined four different medications ordered for G-tube administration into a single medication cup for a resident, contrary to facility policy requiring crushed medications to be prepared in separate cups unless specifically approved by the prescriber. Review of physician orders confirmed the medications involved included an anticoagulant, an iron supplement, a delayed-release GI medication, and PRN acetaminophen, and the DON acknowledged that combining these medications in one cup did not meet facility expectations, contributing to a 12.5% med error rate during the survey sample.
A resident’s call light was found placed between the mattress and bed rail, making it inaccessible while the resident was in bed. The resident confirmed being unable to reach the call light, and a CNA acknowledged that the device was not within reach and should always be accessible to the resident. This reflects a failure to ensure the call system was available and within reach in the resident’s room and bathroom/bathing area as required.
Three residents with significant physical and/or cognitive impairments did not consistently receive scheduled bathing or showering assistance as required by their care plans, with facility records showing multiple extended periods without documentation of bathing offers or assistance. Interviews and documentation confirmed that the established shower schedule was not followed for these residents.
A suicide attempt by a resident was not reported to the State Agency within the required 24-hour period. The incident report was submitted several days late, and this delay was confirmed by the Regional Nurse Consultant during an interview.
The facility did not ensure residents had access to their money, affecting all 95 residents. A resident reported being denied funds after receiving a large check, with the facility claiming they had run out of money. The Resident Council members confirmed that money was often unavailable, especially on weekends. The Business Office Manager admitted the facility had no cash on hand for thirteen days, despite expectations from the Regional Business Office Manager to have cash available at all times.
The facility did not ensure residents received mail on Saturdays, impacting all 95 residents. Residents reported delays in receiving important items, such as personal supplies. The Activities Director confirmed mail is not delivered on weekends due to her being the sole staff responsible for mail delivery. The Regional Social Services Consultant expects daily mail delivery.
A facility failed to ensure a nurse aide completed a NATCEP or CEP within four months of employment. The aide was hired in July and certified in December, exceeding the required timeframe. The HR Director confirmed the delay, and the aide continued working during this period, potentially affecting the care of 95 residents.
The facility failed to ensure meals were attractive, palatable, and at safe temperatures. Observations showed undercooked and unappetizing food, with residents expressing dissatisfaction with taste and spiciness. Food temperatures were not maintained, and meal service timing was inconsistent, with delays of up to 15 minutes for residents at the same table. The Dietary Manager was unaware of complaints and acknowledged the need for timely service.
The facility did not provide nutritionally equivalent alternative meal options for its 95 residents, as revealed by a review of the September 2024 menu and staff interviews. The menu offered only one meal option per mealtime, and the 'always available' menu was not nutritionally comparable to the main meals. The Vice President of Nutrition and the Dietary Manager confirmed the lack of equivalent alternatives.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including unsanitary conditions, lack of proper labeling and dating of food items, and improper food handling. The Dietary Manager confirmed the absence of sanitizer in cleaning buckets and incomplete monitoring logs. Maintenance issues included a leaking plumbing line and a dishwasher with inadequate temperature and sanitizing solution.
The facility failed to involve residents in their care planning process. One resident, with a BIMS score indicating cognitive intactness, had not participated in a care plan meeting since admission. Another resident was not invited to attend meetings, and a meeting was held while they were hospitalized. A third resident, with moderate cognitive impairment, expressed a desire to attend meetings but was not invited, despite having a POA.
The facility failed to respect the choices of two residents, leading to deficiencies in promoting self-determination. One resident experienced staff entering her room without knocking, while another had her preference for oxygen tube placement ignored by an LVN. These actions disregarded the residents' expressed wishes and affected their dignity and comfort.
The facility did not ensure grievances from the Resident Council were resolved and communicated back to the committee. Residents felt discouraged from filing grievances, and when they did, responses were delayed. The Activity Director noted delays in receiving completed grievance forms from department heads, which hindered timely communication to residents. The Regional Social Services Consultant described the expected grievance process but was unsure if outcomes were discussed in Resident Council meetings.
The facility failed to conduct accurate assessments for two residents, resulting in unaddressed dental needs. One resident's MDS inaccurately showed no dental issues despite visible problems, while another resident's MDS was incomplete, lacking dental status information. The MDS coordinator confirmed these errors.
Several residents with complex medical conditions reported not being informed about or offered individualized activities, leading to a deficiency in meeting their needs. The Activity Director confirmed the lack of engagement, particularly for in-room activities, despite residents' preferences and limited documentation of participation.
A resident with multiple diagnoses, including cerebrovascular disease and anoxic brain damage, reported needing eyeglasses due to poor vision. Despite a promise from a previous Social Services Director to schedule an appointment, no such appointment was found in the resident's electronic health record, as confirmed by the Regional Social Services Consultant.
The facility exceeded the acceptable medication error rate, reaching 13.95% due to errors in insulin administration and failure to follow hand hygiene protocols. An LVN administered insulin without holding the dose as required by the physician's order, and an LPN did not sanitize hands during medication administration for multiple residents, violating facility policy.
A resident with Type 2 Diabetes Mellitus was administered insulin despite a blood sugar level below the threshold specified in the physician's order. An LVN gave 46 units of Lantus insulin even though the resident's blood sugar was 118 mg/dl, contrary to the directive to hold the medication if below 120 mg/dl. The Regional Nurse Coordinator confirmed that staff should follow physician orders and facility policy.
The facility failed to provide routine dental care for three residents, resulting in missed dental appointments and lack of follow-up. One resident had missing teeth and desired dentures, another had not received her dentures after fitting, and a third had not had a dental appointment since admission despite a request being made.
An LPN failed to maintain proper hand hygiene during medication administration for three residents, including one who received a subcutaneous injection. The LPN did not sanitize or wash hands before or after resident contact, contrary to facility policy. The DON confirmed the expectation for hand hygiene and glove use, as outlined in the facility's medication administration policy.
The facility failed to document that a resident received or was offered pneumococcal and influenza vaccines, as required by its policies. The resident's medical record lacked consent or declination forms, indicating non-compliance with the facility's vaccination procedures.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. A CNA hired in June 2023 did not complete any training by September 2024, as confirmed by the HR Director. Despite this, the CNA continued to work shifts providing care to residents.
The facility failed to serve meals simultaneously to residents seated at the same dining table, leading to some residents watching others eat while they waited. Interviews revealed residents' preference for simultaneous service, and the Dietary Manager acknowledged the excessive wait time.
A resident with multiple diagnoses, including dementia and repeated falls, experienced 14 falls over 6.5 months due to inadequate interventions and supervision at the facility. Despite being on a blood thinner, the care plan did not address associated risks, and required neurochecks were often incomplete. One-to-one staffing was assigned but not consistently provided, leading to multiple falls and head injuries, ultimately resulting in the resident's death.
A treatment cart was found unlocked and unattended in a hallway between the dining room and nurse's station, posing a risk to resident safety and privacy. A CNA confirmed the cart was unattended, and the ADON stated it should have been locked.
The facility failed to act on grievances raised by three residents, including issues with cold food, improper utensils, unwanted bread, noise during church services, and hunger due to a liquid diet. The Administrator confirmed that grievances were not submitted or resolved, indicating a systemic issue.
The facility failed to maintain the ability of two residents to perform activities of daily living (ADLs) due to the absence of a restorative nursing program. Despite being discharged from various therapies and having care plans indicating the need for further evaluation and support, the residents did not receive the necessary interventions, as confirmed by the Administrator and the Director of Rehabilitation.
The facility staff failed to report incidents of alleged abuse for two residents. One resident, who was cognitively intact, reported that a CNA was standing by her bedside table in the dark, which startled and scared her. Despite her request to not have the CNA return to her room, the CNA continued to be assigned to her care. Another resident, who was moderately impaired, expressed fear of the same CNA to another CNA, but this information was also not reported to the administration.
A facility failed to thoroughly investigate allegations of sexual abuse involving a resident and a CNA. Despite the resident's reports and requests for a different caregiver, the CNA continued to work with her, causing emotional trauma. The facility's response was inadequate, and the CNA was allowed to return to work shortly after being suspended.
The facility failed to prevent staff-to-resident sexual abuse and protect other residents from ongoing sexual behaviors. A resident reported inappropriate behavior by a CNA, who continued to be assigned to her care despite her request for a different caregiver. Another resident also reported inappropriate behavior by the same CNA. The facility's investigation and response were inadequate, leading to ongoing distress and fear among the residents.
Misappropriation of Resident Funds via Unauthorized Use of Payment App
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s money when a CNA used the resident’s payment app account without permission. The resident had multiple medical conditions, including hypertrophic cardiomyopathy, NSTEMI, type 2 DM, GERD, and a cognitive communication deficit, and had a BIMS score of 11, indicating moderately impaired cognition. According to the facility’s initial incident report, the resident reported that a CNA took her phone without her knowledge and transferred $100.00 from her personal payment app account. The facility’s investigative narrative documented that $100.00 was withdrawn from the resident’s payment app account on 12/16/25 and that the CNA used the resident’s phone to transfer the $100.00 to the CNA’s personal payment app account. During an interview, the resident stated that she did not know the CNA had used her phone and that she had never given the CNA permission to use it. She discovered the missing money when she received her bank statement the following month. In a separate interview, the Administrator stated that the resident’s son contacted the facility to report that the CNA had transferred $100.00 of the resident’s money to the CNA’s personal account. The Administrator stated that his investigation confirmed the allegation of exploitation by the CNA.
Failure to Update and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required daily nurse staffing information 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 12/14/25 at 12:15 p.m., an observation showed that the staffing data posting was dated 12/11/25, indicating it had not been updated for several days. During an interview at 12:32 p.m. on the same day, the Admissions Coordinator confirmed that the posted staffing information was for 12/11/25 and acknowledged it had not been updated daily. This deficient practice had the potential to affect all 96 residents in the facility, as identified by the Admissions Coordinator, and could likely result in residents and visitors not having the staffing information readily available.
Expired Insulin Pens Found in Medication Storage Refrigerator
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when expired insulin products were found in a medical supply storage refrigerator. On 12/18/25 at 10:05 a.m., observation of the medical storage room refrigerator revealed one Novolog Mix 70/30 Flex Pen with an expiration date of 03/31/24 and three additional Novolog Mix 70/30 Flex Pens with an expiration date of 06/30/25. These expired medications were stored in the medical supply storage area rather than being removed and disposed of. During a subsequent interview on 12/19/25 at 10:07 a.m., an LPN confirmed that the insulin pens were expired and acknowledged they should have been properly disposed. This failure to keep the medical supply storage rooms free of expired medications was cited as noncompliance with requirements for safe storage of drugs and biologicals, and the deficient practice was noted as having the potential to affect all 96 residents in the facility, as identified by the census provided by the Administrator on 12/14/25.
Failure to Perform Regular Bed Safety Inspections and Maintenance
Penalty
Summary
The facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 13 residents. Surveyors determined that bed evaluations, assessments, and regular maintenance, which should have been completed for all residents’ beds, had not been done. The deficiency involved the lack of routine safety checks to ensure that all bed rails and mattresses were safely attached to the bed frames and to identify potential entrapment zones between the mattress, side rail, footboard, and headboard. During an interview, the DON and the Administrator acknowledged that bed evaluations, assessments, and regular maintenance for residents’ beds were expected to be completed but had not been carried out, and they stated that this did not meet their expectations for safety. The report cross-referenced related findings under tag 700A, indicating that the identified issue was part of a broader concern regarding bed safety inspections and maintenance.
Psychotropic Medications Used Without Appropriate Diagnosis or Time-Limited PRN Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure psychotropic medications were medically necessary, tied to appropriate diagnoses, and ordered in accordance with regulatory requirements. One resident was admitted with diagnoses including insomnia, major depressive disorder, and psychotic disorder. This resident had a physician order for PRN lorazepam 0.5 mg by mouth every 4 hours as needed for anxiety and restlessness, starting on 11/11/25. The December 2025 MAR showed the medication was administered multiple times during the month. However, the PRN lorazepam order was not limited to 14 days and did not specify a duration, and the resident did not have a diagnosis of anxiety. During interview, the DON confirmed the absence of a 14‑day limit or duration for the PRN psychotropic order and acknowledged that the resident lacked an anxiety diagnosis. Another resident was admitted with diagnoses including schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety disorder. This resident had an order for olanzapine 10 mg by mouth twice daily for “mood,” starting 03/27/24, and trazodone 75 mg by mouth at bedtime for insomnia, starting 04/21/25. The December 2025 MAR showed the resident received olanzapine twice daily and trazodone daily from 12/01/25 through 12/15/25. The DON confirmed that “mood” was not an appropriate indication for olanzapine and that the resident did not have a diagnosis of insomnia despite receiving trazodone for that indication. The DON stated these practices did not meet her expectations and that medications should have an appropriate indication of use related to the resident’s diagnosis, and PRN psychotropics should either indicate duration or be limited to 14 days.
Failure to Complete Timely and Accurate Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, complete baseline care plans within 48 hours of admission for multiple residents. For one resident admitted with fractures of the left humerus and right radius, depression, and anxiety, record review showed that the baseline care plan, dated several days after admission, was not completed and signed until thirteen days post-admission, missing the 48-hour requirement. The DON confirmed that this baseline care plan did not meet her expectations due to the late completion. Another resident admitted with a sacral fracture, HTN, osteoarthritis, and urinary retention had a baseline care plan marked completed on the admission date but not signed by the last author (the activity director) until eighteen days after admission, also missing the 48-hour deadline, which the DON acknowledged did not meet her expectations. A third resident admitted with a displaced intertrochanteric femur fracture, chronic respiratory failure with hypoxia, collapsed lumbar vertebra, wedge compression fractures at T11–T12, gastrostomy status, history of chemotherapy and irradiation, and long-term anticoagulant use was observed with a feeding pump connected to a gastrostomy tube. The MDS documented current tobacco use and anticoagulant therapy, but the baseline care plan did not indicate that the resident was a current smoker, did not document current anticoagulant use, and contained no information in the nutritional services section. The DON stated that this baseline care plan did not meet her expectations because it omitted the resident’s smoking status, anticoagulant use, and feeding tube.
Failure to Revise Care Plans for Bed Rail Use and Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans to reflect residents’ current needs and the use of bed rails. For one resident with morbid obesity, muscle weakness, lack of coordination, and a need for assistance with personal care, the care plan revised on 11/11/25 did not include any interventions for the use of bed rails, despite quarter-size bed rails being present on both upper sides of the bed and the resident confirming she used them for positioning and mobility. Another resident with major depressive disorder, insomnia, anxiety disorder, hyperlipidemia, and heart failure had a physician’s order, effective since 01/09/23, for quarter-size bed rails for mobility and transfers, and quarter-size bed rails were observed on both upper sides of the bed; however, the care plan revised on 11/11/25 contained no interventions addressing bed rail use. The DON confirmed that this care plan had not been revised to include bed rail use. A further deficiency was identified for a resident with esophagitis, anxiety disorder, anemia in chronic kidney disease, muscle weakness, end-stage renal disease, systolic congestive heart failure, and fatty liver, who was observed to be unable to turn and reposition without assistance and had quarter-size bed rails on both sides of the bed. The MDS dated 12/02/25 documented that this resident was dependent on staff for bed mobility, but the care plan dated 06/03/24 still stated the resident could turn and reposition independently, and the DON acknowledged the care plan should have been revised to reflect dependence on staff. Another resident with a history of falling, lack of coordination, hyperlipidemia, depression, need for assistance with personal care, and chronic systolic congestive heart failure was observed with bed rails in use, yet the care plan was not revised to indicate the use of quarter bed rails for bed mobility and transfers until 12/17/25. The DON confirmed that this care plan had not been updated prior to that date to reflect bed rail use.
Failure to Assess, Order, and Obtain Consent for Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required processes before and during the use of bed rails for multiple residents. The facility did not consistently obtain physician orders, complete entrapment risk assessments, review risks and benefits with residents or their representatives, obtain informed consent, or ensure that bed rail use was reflected in care plans and Minimum Data Set (MDS) assessments. Surveyors observed quarter-size bed rails in use for 13 residents, while corresponding medical records frequently lacked documentation of orders, assessments, consents, and in some cases care plan interventions for bed rail use. The report states that this deficient practice has the potential to cause serious injury by residents becoming trapped between the mattress and bed rail. For one resident with morbid obesity, muscle weakness, lack of coordination, and need for assistance with personal care, surveyors observed quarter-size bed rails on both upper sides of the bed. The care plan contained no interventions for bed rail use, and the electronic health record lacked a physician order, entrapment risk assessment, and consent, although bed dimensions were documented as appropriate. Another resident with schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety had quarter-size bed rails in place and used them for positioning and mobility; the care plan documented bed rail use, but there were no physician orders, entrapment assessments, or consents. A resident with multiple medical conditions including ESRD, muscle weakness, and heart failure had 1/4 side rails in use and care plan documentation for assist bars, but the record lacked an entrapment risk assessment, risk/benefit review, consent, and documentation of appropriate bed dimensions. Additional residents with diagnoses such as muscle wasting/atrophy, COPD, asthma, epilepsy, generalized muscle weakness, spinal stenosis, depression, insomnia, anxiety, and history of falls were also observed with quarter-size bed rails in use. For several of these residents, care plans either did not include bed rail interventions or were updated only after surveyor observations, and physician orders for bed rails were often missing. In multiple cases, MDS assessments and care plans did not reflect actual bed rail use, and medical records lacked documentation of entrapment risk assessments, risk/benefit discussions, and informed consent. Some residents and a representative confirmed that bed rails were used for positioning, mobility, and transfers. The Administrator and DON acknowledged during interviews that residents did not have the appropriate requirements in place for bed rails, including therapy assessments/referrals, physician orders with indication of use, education with consent, and updated care plans. The pattern across all 13 residents reviewed for accidents shows that bed rails were installed and in use without the facility completing the required safety and consent processes. Several residents had quarter-size bed rails on both sides of the bed despite the absence of corresponding physician orders and documentation in the care plan or MDS. The report notes that for each of these residents, there was no documented assessment for risk of entrapment and no documented review of risks and benefits or consent for bed rail use, even though bed dimensions were often documented as appropriate for the resident’s size and weight. This systemic failure to assess, document, and obtain consent for bed rail use constitutes the cited deficiency.
Failure to Ensure Medications Match Current Diagnoses and Indications
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary medications by not aligning indications for use with residents’ current diagnoses for three residents. One resident was admitted with diagnoses of insomnia, major depressive disorder, and psychotic disorder. Physician orders showed this resident was prescribed cetirizine for seasonal allergies, acetaminophen for pain, and tramadol as needed for pain. The MAR documented that cetirizine and acetaminophen were administered routinely over multiple days and tramadol was administered on several specific dates and times. During interview, the DON confirmed this resident did not have diagnoses of seasonal allergies or pain and stated the indications for cetirizine, acetaminophen, and tramadol did not reflect the resident’s current diagnoses or treatment of symptoms related to those diagnoses. Another resident was admitted with schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety disorder. This resident had a physician order for methotrexate sodium 15 mg weekly for rheumatoid arthritis, and the MAR showed the medication was administered on two dates in December. The DON confirmed this resident did not have a diagnosis of rheumatoid arthritis and stated the indication for methotrexate did not reflect the resident’s current diagnoses or treatment of related symptoms. A third resident was admitted with major depressive disorder, insomnia, anxiety disorder, hyperlipidemia, and heart failure. This resident had a physician order for Zyrtec 10 mg daily via G-tube for allergies, and the MAR showed daily administration over multiple days. The DON confirmed this resident did not have a diagnosis of allergies and stated the indication for Zyrtec did not reflect the resident’s current diagnoses or treatment of related symptoms.
Unsanitary Food Storage, Kitchen Conditions, and Improper Food Service Practices
Penalty
Summary
Surveyors identified multiple failures in food procurement, storage, sanitation, and service. In the dining area, the ice and water machine had dried residue and what appeared to be dried food particles and splatters on the outside of the machine and the table it sat on. In the satellite kitchen’s resident refrigerator, surveyors found numerous expired and improperly stored items, including yogurt and milk past their expiration dates, unlabeled and undated discolored fruit, a plate of turkey, mashed potatoes, and stuffing labeled for Resident #48 from 11/27/25, two pans of mac and cheese dated 11/28/25, and a turkey leg wrapped in plastic wrap dated 11/28/25. In the same satellite kitchen refrigerator, there were multiple unlabeled and undated pitchers of orange and red liquids, a bowl of lettuce, tomato, and onion with no label or date, and tubs containing approximately 40 individual containers each of mayonnaise and Jello with no labels or dates. The trashcan near the handwashing sink was overflowing and could not close completely. The Dietary Aide #1 confirmed that all items in the refrigerators should have been labeled and dated, and that leftovers should be discarded after three days, acknowledging that the leftovers present were old. Additional observations showed that the kitchen environment was not maintained in a clean and sanitary manner. The wall behind the handwashing sink in the satellite kitchen was covered with what appeared to be dirty, dried food particles and dried liquid splash marks. In the main kitchen, a floor drain in the corner was full of what appeared to be food particles and liquid, which had overflowed onto the surrounding floor; the kitchen floor overall was dirty with food particles, trash, and spilled liquids. The cart used to store clean pots and pans was covered with what appeared to be food particles and dried liquid splashes, and a trash can near the food preparation table was overflowing so that its lid could not close properly. The temperature tracking sheet on the outside of a refrigerator was last dated November 2025. During an interview, the Regional Nutritionist declined to state whether the kitchen areas met her expectations. In addition, surveyors observed Resident #101 opening a food tray delivery cart, removing a bowl of vegetables belonging to another resident, and having another resident request staff to heat the food; CNA #1 then reheated and served this food to Resident #101, later acknowledging that serving food provided by another resident violated proper sanitary practices.
Failure to Implement Enhanced Barrier Precautions and Signage for Residents with Wounds and Indwelling Devices
Penalty
Summary
Surveyors identified a failure to maintain proper infection prevention and control measures related to Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) for three residents. One resident with multiple pressure ulcers, including two stage 3 pressure ulcers, one stage 4 pressure ulcer, one unstageable pressure ulcer due to a non-removable dressing or device, and one unstageable pressure ulcer/injury presenting as deep tissue injury, did not have an EBP sign posted at the entry of the room during observation. Another resident receiving enteral feeding via a gastrostomy tube also did not have an EBP sign posted at the room entrance. In both of these cases, PPE was noted as being readily available at the entry to the rooms, but the required EBP signage was missing. A third resident with a physician order for EBP due to the presence of a Foley catheter likewise did not have an EBP sign posted at the room entrance during observation. A CNA confirmed that there was no EBP sign posted for this resident. In an interview, the DON confirmed that residents with pressure ulcers, enteral feeding tubes, and Foley catheters require EBP signs posted outside their rooms with PPE available for staff, and stated that her expectation is that residents with open wounds or indwelling devices should have precautions in place and followed. The observations and interviews demonstrated that EBP signage was not consistently posted as required for these residents, despite the facility’s stated expectations.
Resident Unable to Watch Preferred Television Programming After Power Strip Removal
Penalty
Summary
Surveyors identified a deficiency related to resident choice and dignity when a resident was not provided activities according to her stated preferences. Record review showed the resident was admitted on the documented admission date and had a care plan, revised on 06/22/24, indicating she preferred activities that aligned with her prior lifestyle, including current events, educational programs, movies, sports, and television. During an interview on 12/14/25 at 3:52 p.m., the resident reported she was upset because staff had removed the power strip that allowed her television to reach the electrical outlet earlier that morning, and she could no longer watch television; she stated staff told her it was a safety hazard. Review of the facility’s “Electrical Safety for Residents” policy, revised January 2011, showed requirements for safe use of power strips, including internal ground faults and over-current protection, securing strips to avoid trip hazards, and ensuring adequacy for the number and type of devices. In an interview on 12/17/25 at 1:33 p.m., the Administrator confirmed the power strip had been removed from the resident’s room and acknowledged that, while the facility was consulting an electrician to change outlets, no alternatives had been implemented to allow the resident to continue watching television in her room. This sequence of events resulted in the resident being unable to access a preferred activity—watching television—despite her documented preferences and the facility’s responsibility to promote and facilitate resident self-determination and choice.
Inconsistent Documentation of Resident Advance Directives Across Medical Record
Penalty
Summary
The facility failed to ensure that residents’ advance directive wishes were consistently documented across the Electronic Health Record (EHR), MOST forms, physician orders, and care plans for multiple residents. For one resident, the EHR face sheet listed the code status as Attempt Resuscitation/CPR, the physician’s order directed Attempt Resuscitation/CPR, and the care plan documented the resident as Full Code, while the signed MOST form indicated the resident’s choice was Do Not Resuscitate (DNR). The DON confirmed that the MOST form conflicted with the face sheet, physician orders, and care plan, and acknowledged that all advance directive documentation should match throughout the chart. For a second resident, the admission record showed the resident’s entry into the facility, and the signed MOST form documented a choice of DNR, but the current physician orders directed Attempt Resuscitation/CPR and the care plan did not indicate any advance directive. For a third resident, the face sheet and MOST form both indicated DNR, but the physician’s orders listed the advance directive as Full Code/CPR and the care plan did not include any advance directive information. In interviews, the DON confirmed that the physician orders and care plans for these residents did not match the signed MOST forms and stated that this did not meet her expectations for consistent documentation of advance directives.
Failure to Complete Accurate and Timely Baseline Care Plans on Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s development of accurate baseline care plans within 48 hours of admission for multiple residents. For one resident with metabolic encephalopathy and end-stage renal dialysis, the baseline care plan lacked any information in the Social Services, Rehabilitative Services, and Activities sections, and incorrectly listed a regular diet in the Nutritional Services section. The DON stated this baseline care plan was not accurate and not completed to her expectations. Another resident admitted with fractures of the left humerus and right radius, depression, and anxiety had a baseline care plan that was not completed and signed until thirteen days after admission, which the DON confirmed did not meet her expectations due to the delay. A third resident admitted with a sacral fracture, essential hypertension, osteoarthritis, and urinary retention had a baseline care plan marked completed and fully signed eighteen days after admission, which the DON acknowledged did not meet her expectations. For a fourth resident with multiple serious conditions including a displaced intertrochanteric fracture of the right femur, chronic respiratory failure with hypoxia, vertebral fractures, gastrostomy status, history of chemotherapy and irradiation, and long-term anticoagulant use, observation showed a feeding pump connected to a tube in the abdomen and the resident reported having a feeding tube for eight years. However, the baseline care plan did not indicate that the resident was a current smoker, did not document current anticoagulant use, and contained no information in the Nutritional Services section. The DON stated this baseline care plan should have documented smoking status, anticoagulant use, and feeding tube use but did not.
Crushed Medications Improperly Combined for G-Tube Administration, Exceeding Acceptable Med Error Rate
Penalty
Summary
Surveyors identified a deficiency in medication administration when staff failed to maintain a medication error rate below 5%, documenting four errors out of 32 opportunities (12.5%) during medication administration observations. During one observation of medication administration via feeding tube for Resident #106, an LVN prepared four different medications by crushing or pouring them from capsules and combined all four into a single medication cup before administration. Record review showed physician orders for Eliquis 5 mg via G-tube, Ferrous Sulfate 325 mg via G-tube, Pantoprazole Sodium delayed-release tablet via G-tube, and Tylenol 325 mg, two tablets via G-tube every six hours as needed for pain. The facility’s policy dated 04/12/23 stated that crushed medications are not to be mixed into the same medicine cup unless approved by the prescribing physician. In an interview, the DON stated that medications should be prepared in separate medicine cups before administering them through a feeding tube and confirmed that combining crushed medications into one cup did not meet her expectations. This deficient practice resulted in a calculated medication error rate of 12.5%, exceeding the regulatory threshold of 5% for medication errors during the survey review of six residents receiving medication administration.
Call Light Not Kept Within Reach for Resident in Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s call light was within reach while the resident was in the room. During a random observation of Resident #5’s room on 12/15/25 at 9:57 a.m., the surveyor observed that the resident’s call light was positioned on the side of the bed, between the mattress and the bed rail, rather than in an accessible location. At 9:58 a.m., Resident #5 confirmed in an interview that he could not reach his call light. At 10:02 a.m., CNA #3 was interviewed and confirmed that Resident #5’s call light was not within his reach and acknowledged that the call light should always be within the resident’s reach. These observations and interviews showed that the facility did not ensure a working call system was available and accessible to the resident while in the room, as required.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled activities of daily living (ADL) assistance, specifically with bathing or showering, for three residents who required varying levels of staff support. Documentation and interviews revealed that these residents, each with significant medical conditions such as cognitive impairment, muscle weakness, mobility issues, and a history of falls, did not consistently receive showers or baths according to their care plans and the facility's established shower schedule. For example, one resident, who was cognitively intact but physically dependent, reported not receiving showers three times a week as ordered, with records confirming multiple gaps of six to seven days without documentation of bathing assistance or offers. Similarly, another resident requiring partial to moderate assistance and a third resident with severe cognitive impairment and total dependence both experienced extended periods without documented bathing or showering, despite being scheduled for showers three times weekly. Facility records showed multiple instances where there was no documentation that these residents were offered or assisted with bathing, and in one case, only a single refusal was recorded during a prolonged gap. The Regional Nurse Consultant confirmed that the shower schedule was not followed for these residents.
Failure to Timely Report Suicide Attempt to State Agency
Penalty
Summary
The facility failed to report a suicide attempt involving one resident to the State Agency within the required 24-hour timeframe. Record review showed that the initial incident report for the resident's suicide attempt was not submitted until several days after the event. During an interview, the Regional Nurse Consultant confirmed that the report was not submitted in a timely manner as required by regulations. This delay in reporting meant that the State Agency was not promptly informed of the incident.
Failure to Provide Residents Access to Their Funds
Penalty
Summary
The facility failed to ensure residents had ready and reasonable access to their money, affecting all 95 residents. During interviews, a resident reported receiving a large check but was denied access to funds, with the facility claiming they had run out of money. The resident also mentioned that money was never given out on weekends. The Resident Council members corroborated this, stating that staff frequently told them money was unavailable, especially on weekends. The Business Office Manager confirmed that a check for the resident was deposited and cleared, but the facility had no cash on hand for residents for thirteen days. The Regional Business Office Manager expected the facility to have cash available for residents at all times.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents have reasonable access to their mail on Saturdays, affecting all 95 residents. During a Resident's Council Meeting, several residents expressed that mail is not delivered on Saturdays, which has led to delays in receiving important items, such as personal incontinence supplies. One resident reported waiting up to two days for packages. The Activities Director confirmed that mail is not delivered on weekends because she is the only staff member responsible for mail delivery, and if she is not working, the mail remains undelivered. The Regional Social Services Consultant stated that he expects mail to be delivered daily to residents.
Failure to Ensure Timely Certification of Nurse Aide
Penalty
Summary
The facility failed to provide documentation confirming that a nurse aide, employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed. The nurse aide was hired on July 17, 2023, and did not receive certification until December 8, 2023, which is beyond the four-month requirement. During an interview, the Human Resources Director confirmed that the nurse aide received her certification late and continued to work shifts during that time. This deficiency is likely to affect all 95 residents residing in the facility, as they may experience substandard care due to the use of untrained or unqualified aides providing direct care.
Deficiencies in Meal Service and Food Quality
Penalty
Summary
The facility failed to ensure that meals served to residents were attractive, palatable, and at safe temperatures. Observations revealed that a resident received an undercooked hamburger, and another resident was served a grilled cheese sandwich with unmelted cheese. Several residents expressed dissatisfaction with the taste and spiciness of the food, with some stating that they were not offered alternative meal choices. The Dietary Manager was unaware of these complaints and stated that adjustments could be made if informed. The facility also failed to maintain appropriate food temperatures. A test tray observation showed that the chicken was served at 95°F, which is below the recommended temperature for hot foods. Additionally, a kitchen staff member was unable to provide the correct holding temperatures for food items. An incident was noted where tomato soup had to be reheated after being found at 115°F, and then it was overheated to 200°F. Furthermore, the timing of meal service was inconsistent, with residents at the same table receiving their meals at different times, sometimes with a delay of up to 15 minutes. This was confirmed by the Dietary Manager, who acknowledged that such delays were too long and that residents should be served at or around the same time. These deficiencies have the potential to affect all 95 residents' ability to enjoy meals and may decrease their quality of life.
Failure to Provide Nutritionally Equivalent Meal Alternatives
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of all 95 residents as indicated by the facility census. This deficiency was identified through a record review and interviews, revealing that the facility did not provide an alternative meal option for breakfast, lunch, and dinner that was equal in nutritional value to the primary meal. The posted menu for September 2024 showed only one meal option per mealtime, without a nutritionally equivalent alternative. Interviews with the Vice President of Nutrition and the Dietary Manager confirmed that while an 'always available' menu existed, it did not match the nutritional value of the main meals served. The Vice President of Nutrition acknowledged that the everyday menu might have different calorie content, and the Dietary Manager stated that there should be two meal options, but the alternative provided was not comparable to the main meal.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially affect all 95 residents. During an inspection, several unsanitary conditions were observed, including a sticky floor, hard water deposits around the kitchen sink, and a soiled rag in the dishwasher area. Additionally, the dishwashing room had wet floors with large food pieces underneath the sink, and the eye wash station was soiled with a dark brown substance. A transfer cart near clean dishes was dirty with food particles, and sanitation buckets used for cleaning prep areas contained dirty water without sanitizing solution. The Dietary Manager (DM) confirmed the absence of sanitizer in the cleaning buckets, which should always contain sanitizer and be changed every two hours. The DM also found that the 5-gallon refill container of sanitizer was empty and dry. Furthermore, the Service Opening and Closing monitoring logs were incomplete for certain shifts, indicating a lack of routine checks on refrigerator temperatures, equipment, and sanitizing solutions. Food items on transportation racks were not labeled and dated, and the refrigerator contained a soiled blue platform used for storing food items. Improper food handling was also noted, with uncovered and unwrapped ham and cheese left at room temperature, and a resident's food ticket dropped into chicken on the steam table, which was then served. The DM confirmed that the chicken was not fit to serve. Additionally, maintenance issues were identified, such as a leaking plumbing line in the dishwashing area and a dishwasher with a wash cycle temperature below the required level and insufficient sanitizing solution. These deficiencies highlight significant lapses in food safety and sanitation practices within the facility.
Failure to Ensure Resident Participation in Care Planning
Penalty
Summary
The facility failed to ensure the participation of residents in the care planning process, affecting three out of five residents reviewed. Resident #24, who was admitted with multiple diagnoses including cerebrovascular disease and bipolar disorder, had a BIMS score indicating cognitive intactness but had not participated in a care plan meeting since admission. The resident confirmed the absence of a Power of Attorney and the lack of a care plan meeting, which was corroborated by the Regional Social Services Consultant. Resident #30, admitted with conditions such as respiratory failure and hypertensive heart disease, was not invited to attend care plan meetings despite having no Power of Attorney. A care plan meeting was held while the resident was hospitalized, which the RSSC acknowledged as inappropriate. Resident #96, with a BIMS score indicating moderate cognitive impairment, expressed a desire to attend care plan meetings despite having a Power of Attorney. The resident stated she was never invited to participate, contradicting the facility's records that indicated her POA attended meetings on her behalf.
Failure to Honor Resident Choices
Penalty
Summary
The facility failed to honor the choices of two residents, leading to deficiencies in promoting resident self-determination. For one resident, staff repeatedly entered her room without knocking, despite her expressing frustration and reporting the issue to the Administrator. This lack of respect for her privacy and dignity was confirmed during an interview with the Regional Social Services Consultant, who emphasized the importance of knocking and announcing oneself before entering a resident's room. Another resident's preference to have her oxygen tube attached to the bed rail was disregarded by a Licensed Vocational Nurse (LVN). Despite the resident's repeated requests to keep the tube off the floor to avoid germs, the LVN untied the fabric securing the tube, allowing it to fall to the floor, and discarded the fabric. This action visibly upset the resident, who felt her preferences were being ignored. The Regional Nurse Coordinator later stated that the nurse should have listened to the resident and respected her choice, especially since there was no health reason to remove the fabric.
Failure to Resolve and Communicate Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances identified by the Resident Council were resolved and communicated back to the committee. During interviews, Resident Council members expressed that the facility discouraged them from filing grievances and did not respond to their grievances in a timely manner, if at all. The Activity Director mentioned that she fills out grievance forms and submits them to the appropriate department head, but the process of getting the forms back with resolutions has taken several weeks, delaying communication to the residents. The Regional Social Services Consultant outlined the expected process for handling grievances, which includes assisting residents in writing grievances, logging them for internal tracking, submitting them to the appropriate department head, and notifying residents of the outcomes in a manner they understand. However, the consultant was unsure if grievances or their outcomes were discussed during Resident Council meetings, although he stated they should be. This lack of timely response and communication regarding grievances could potentially affect all 95 residents at the facility.
Inaccurate and Incomplete Resident Assessments
Penalty
Summary
The facility failed to complete accurate comprehensive assessments for two residents, leading to deficiencies in their care. One resident expressed a need for dental care, noting missing teeth and discoloration, but the Minimum Data Set (MDS) assessment inaccurately indicated no dental problems. The MDS coordinator confirmed the error in the dental information. Another resident expressed a desire for dentures and reported not having a dental appointment since admission. The MDS assessment for this resident was incomplete, with the oral and dental status section left blank. The MDS coordinator acknowledged the omission.
Deficiency in Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests of several residents, leading to a deficiency in individualized care. Resident #22, who has multiple diagnoses including Type 2 Diabetes Mellitus, Schizophrenia, Bipolar Disorder, and Cerebral Palsy, reported not being informed about or offered any activities since admission. The Activity Director confirmed that no activities, particularly in-room activities, were offered to Resident #22, despite knowing her preference for staying in her room. Resident #24, with conditions such as Bipolar Disorder, Anxiety Disorder, and Anoxic Brain Damage, expressed that she does not attend activities due to a lack of fitting clothes and has not been offered in-room activities. Although the Activity Director stated that Resident #24 participates in room activities, the Electronic Health Record showed limited documentation of her involvement in activities, with only a few instances noted over several months. Resident #30, who has been diagnosed with Acute and Chronic Respiratory Failure, Muscle Weakness, and Hypertensive Heart Disease, stated a preference for in-room activities but reported not being offered any since readmission. Similarly, Resident #90, with diagnoses including Cellulitis, Chronic Viral Hepatitis C, and End Stage Renal Disease, indicated he was unaware of any activities and had not been approached by the Activity Director since admission. The lack of engagement and individualized activity offerings for these residents highlights a deficiency in meeting their needs and interests.
Failure to Schedule Vision Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision, which could likely result in a loss of independence and compromised quality of life. The resident was admitted with multiple diagnoses, including cerebrovascular disease, bipolar disorder, anxiety disorder, anoxic brain damage, and difficulty in walking. During an interview, the resident expressed the need for eyeglasses due to poor vision and mentioned that a previous Social Services Director had promised to schedule an appointment, which had not yet occurred. A review of the resident's electronic health record by the Regional Social Services Consultant confirmed the absence of any scheduled vision appointment.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 13.95% error rate during medication administration for four out of seven residents observed. One significant error involved a Licensed Vocational Nurse (LVN) administering 46 units of Lantus insulin to a resident without holding the dose despite the resident's blood glucose level being below the threshold of 120 mg/dl, as per the physician's order. This oversight in following the physician's directive could lead to improper blood sugar management for the resident with diabetes mellitus type 2. Additionally, the facility's staff did not adhere to proper hand hygiene protocols during medication administration. An LPN was observed failing to sanitize hands before and after preparing and administering medications to multiple residents. This practice was contrary to the facility's Medication-Administration policy, which mandates handwashing before and after medication administration. The Regional Nurse Coordinator confirmed that staff should comply with physician orders and facility policies, including hand hygiene, during resident interactions.
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors by not adhering to the physician's orders for insulin administration. A resident with a diagnosis of Type 2 Diabetes Mellitus and a foot ulcer was prescribed Lantus insulin to be administered subcutaneously once a day, with specific instructions to hold the medication if the blood sugar level was below 120 mg/dl. On the morning of September 18, 2024, a Licensed Vocational Nurse (LVN) administered 46 units of insulin to the resident despite the blood sugar level being 118 mg/dl, which was below the threshold specified in the physician's order. During an interview conducted on the same day, the LVN confirmed that the resident's blood sugar level was indeed 118 mg/dl prior to administering the insulin. This action was contrary to the physician's directive to withhold the insulin under such circumstances. The Regional Nurse Coordinator later stated that staff are expected to follow physician orders and facility policy regarding medication administration. This incident highlights a significant medication error due to the failure to adhere to prescribed medical instructions.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that residents received routine dental care, affecting three residents. Resident #22 was admitted to the facility and was observed with missing teeth, tooth decay, and discoloration. She reported not being offered dental care and expressed a desire for dentures. The Medical Records/Scheduler indicated that specialty services are scheduled by her, while Social Services handles other appointments. The Regional Social Services Consultant confirmed that Resident #22 had not been offered a dental appointment. Resident #24 reported that her dentures were taken for fitting four weeks prior, but she had not received any updates. The Regional Social Services Consultant stated that the dentures should have been delivered during an appointment that was not documented in the Electronic Health Record. The Medical Records/Scheduler admitted to not following up on the appointment. Resident #75, with a history of muscle wasting and atrophy, had missing teeth and had not had a dental appointment since admission. An email requesting a dental appointment was sent, but no follow-up was completed, and an appointment was never made.
Failure to Maintain Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to administer medications in a manner that prevents cross-contamination for three residents. During a medication administration pass, an LPN was observed preparing and administering medications to residents without sanitizing or washing her hands before or after resident contact. Specifically, the LPN administered medications to one resident, including a subcutaneous injection, without performing hand hygiene before or after the procedure. This practice was repeated with two other residents, where the LPN returned to the medication cart without sanitizing or washing her hands after administering medications. The Director of Nursing confirmed that hand sanitizer should be used before and after contact with each resident and that medications should be administered according to the facility's policy. The facility's policy on medication administration requires washing hands before and after medication administration and wearing gloves when contact with blood or potentially infectious body fluids is anticipated. The failure to adhere to these protocols has the potential to expose residents to pathogens and increase the risk of infection.
Failure to Document Vaccination Offers
Penalty
Summary
The facility failed to ensure that the medical records contained documentation that each resident received or was offered the pneumococcal and influenza vaccines. This deficiency was identified during a record review for one resident out of six reviewed for immunizations. Specifically, the medical record of a resident admitted to the facility did not contain consent forms or declination forms for either vaccination. The facility's policies on Influenza Prevention and Control and Pneumococcal Disease Prevention, which require that vaccines be offered to residents after education, were not followed as there was no documentation of such actions in the resident's electronic health record.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year. Specifically, CNA #1, who was hired on June 27, 2023, did not complete any of the required training hours from her hiring date until September 20, 2024. This was confirmed through a review of CNA #1's personnel file and in-service training transcript report. During an interview, the Human Resources Director acknowledged that CNA #1 had not completed any training during her employment, yet continued to work shifts providing care to residents. The HR Director stated that it was expected for all CNAs to complete at least 12 hours of training per year.
Failure to Serve Meals Simultaneously at Dining Tables
Penalty
Summary
The facility failed to promote care with dignity and respect during a dining observation, affecting four out of six residents reviewed. The issue arose when residents seated at the same dining table were not served their meals simultaneously, leading to some residents having to watch others eat while they waited for their own meals. Specifically, one resident was served at 12:22 pm while another at the same table was served at 12:29 pm. At another table, one resident was served at 12:34 pm, followed by others at intervals up to 12:46 pm. Interviews with the residents revealed their preference to have meals served at the same time as their tablemates, indicating a desire for a more communal dining experience. The Dietary Manager acknowledged that the wait time of seven to twelve minutes was excessive and expressed an expectation for residents at the same table to be served simultaneously or within a few minutes of each other.
Failure to Prevent Falls and Inadequate Supervision
Penalty
Summary
The facility failed to prevent an accident for a resident who sustained 14 falls over a 6.5-month period. The resident, who had multiple diagnoses including dementia, anxiety, and repeated falls, was on a blood thinner medication, Eliquis, which increased the risk of bleeding. Despite being identified as high risk for falls, the facility did not implement adequate interventions to prevent these incidents. The care plan did not address the resident's use of Eliquis or the associated risks, and the facility failed to complete the required neurochecks following unwitnessed falls or falls involving head trauma. The resident's care plan included interventions such as reviewing past falls, considering urinary tract infections as a potential cause, and consulting urology, but these were not effectively implemented. The facility assigned one-to-one staffing for the resident, but staff were often given other duties, leading to inadequate supervision. This lack of supervision resulted in the resident experiencing multiple falls, some of which led to head injuries and required emergency room visits. The facility's failure to complete neurochecks as per policy further exacerbated the situation, as it hindered the monitoring of the resident's neurological status after falls. Interviews with the resident's daughter and staff revealed concerns about the facility's handling of the resident's care. The daughter expressed that the facility did not take sufficient action to mitigate the risk of falls, and the one-to-one staffing was not consistently provided. Staff interviews confirmed that they were assigned additional duties while supposed to be providing one-to-one care, which compromised the resident's safety. These deficiencies likely contributed to the resident sustaining multiple acute subarachnoid hemorrhages and passing away six days after the last fall.
Removal Plan
- Re-evaluation of all residents fall risks and care plans.
- Audit of previous falls to ensure new interventions were put in place and neurological checks were completed.
- Reeducation of staff regarding one-on-one staffing expectations and completing neurological checks.
Unattended and Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure that all treatment carts were locked while unattended, which could potentially affect all 94 residents by allowing unauthorized access to medical supplies and personal health information. During a random observation, a treatment cart located in the short hallway between the dining room and the nurse's station was found unlocked, with no facility employees present in the area. This observation was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the cart was unlocked and unattended. Further confirmation came from an interview with the Assistant Director of Nursing (ADON), who stated that the treatment cart should be locked and secured when not in use. This deficiency highlights a lapse in the facility's protocol for securing medical supplies, posing a risk to resident safety and privacy.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were acted upon for three residents, leading to feelings of neglect and dissatisfaction. Resident #3 reported issues such as receiving cold food, improper eating utensils, unwanted bread, and noise during church services. These complaints were raised during Resident Council meetings but were not addressed by the facility. Similarly, Resident #6 raised concerns about cold food during a Resident Council meeting, but no follow-up actions were taken by the staff. The grievances were documented but not acted upon, as confirmed by the review of Resident Council minutes and grievance reports. Resident #12, who was on a liquid diet due to a broken jaw, reported feeling hungry after meals and experiencing weight loss. This concern was documented in a grievance report but was not followed up by the staff. The Administrator confirmed that grievances from Resident Council meetings were not submitted to the Department Directors or herself, and no resolutions were offered for the issues raised in the meetings. This lack of response and follow-up on grievances was consistent across multiple months, indicating a systemic issue in addressing resident concerns.
Failure to Maintain Residents' ADL Abilities
Penalty
Summary
The facility failed to ensure that residents' ability to perform activities of daily living (ADLs) was maintained for two residents reviewed for restorative therapy. Resident #10 was discharged from physical, occupational, and speech therapy on April 10, 2024, and the care plan indicated that physical therapy was to evaluate for fall prevention. Similarly, Resident #11 was discharged from physical and occupational therapy on April 3, 2024, and from speech therapy on March 27, 2024. The care plan for Resident #11 also indicated a need for physical therapy evaluation for fall prevention and noted a self-care deficit related to confusion and limited mobility. Despite these needs, the facility did not have a restorative nursing program in place at the time of the survey, as confirmed by interviews with the Administrator and the Director of Rehabilitation (DOR). The Administrator mentioned that they were in the process of establishing the program, while the DOR acknowledged the absence of a restorative program and noted that basic activities like walking to dine were encouraged with contact assistance from a Certified Nursing Assistant (CNA). However, the lack of a formal restorative program meant that residents were not receiving the necessary interventions to maintain their ADLs, leading to a potential decline in their functional abilities.
Failure to Report Alleged Abuse
Penalty
Summary
The facility staff failed to report incidents of alleged abuse for two residents. One resident, who was cognitively intact, reported that a CNA was standing by her bedside table in the dark, which startled and scared her. Despite her request to not have the CNA return to her room, the CNA continued to be assigned to her care. The resident reported the incident to an RN, who did not take any action or report the incident further. Another resident, who was moderately impaired, expressed fear of the same CNA to another CNA, but this information was also not reported to the administration. The facility's staff schedule confirmed that the CNA in question continued to work with both residents after the incidents were reported. The failure to report these allegations of abuse to the facility administration meant that no corrective measures were taken, and the residents continued to be exposed to the CNA who made them uncomfortable and scared.
Removal Plan
- The Nurse was educated on abuse reporting.
- The CNA was educated on abuse reporting.
- The facility conducted a safety audit of all residents in the building.
- The facility has begun to conduct random staff questionnaires on abuse and reporting.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to complete a thorough investigation regarding allegations of sexual abuse involving a resident and a CNA. The resident, who was cognitively intact and dependent on care for activities of daily living, reported that the CNA was in her room in the dark without explanation and later applied Desitin cream inappropriately to her pubic area. Despite the resident's request to not have the CNA return to her room, the CNA continued to work with her, causing emotional trauma to the resident. The resident reported the incidents to both an RN and another CNA, but the RN did not report the initial incident, and the facility did not take immediate action to prevent further contact between the resident and the CNA. The facility's records confirmed that the CNA was assigned to work with the resident on multiple shifts, including the dates of the reported incidents. The resident's trauma-informed assessment revealed a history of past trauma and her expressed fear and discomfort with the CNA's presence. Despite this, the facility did not adequately address her concerns or ensure her safety. The resident's reports to staff about the inappropriate touching and her subsequent avoidance of using the call light due to fear were not properly investigated or acted upon. Interviews with staff, including the RN, CNA, and the Director of Nursing, indicated a lack of proper response to the resident's allegations. The facility's administrator acknowledged that the investigation was based on the resident's statement to the police that there was no wrongdoing, attributing the allegations to her past trauma. The CNA was suspended during the investigation but returned to work shortly after. The police report corroborated the resident's account of the incidents and her dissatisfaction with the facility's handling of the situation.
Removal Plan
- The center has implemented a new process to identify residents who may also be affected by an allegation of abuse. The process change includes widening the interview pool to include residents with a BIMS <11 to ensure the identification of others.
- Each state reportable that includes an allegation of abuse or neglect will be reviewed by a corporate partner to ensure interviews were conducted on all residents residing in the center prior to the 5 day being submitted.
- If an employee has an allegation of abuse or neglect against them, the IDT will meet, including Social Services, Human Resources, Director of Nursing, and Administrator, (or their designee) and make a decision to keep or terminate the employee based on the investigation.
- The RNC nurse consultant educated the Administrator and Director of Nursing on performing interviews with all residents that could be at risk of an alleged incident.
Failure to Prevent Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident sexual abuse and to protect other residents from ongoing sexual behaviors. Resident #1 reported that she woke up startled in the early morning hours and found a CNA standing by her bedside table. Despite her request to not have this CNA return to her room, he continued to be assigned to her care. On a subsequent occasion, the CNA applied Desitin cream inappropriately to her vaginal area, causing her significant emotional distress. The resident reported the incident to another CNA, who found her in a puddle of urine the next morning because she was too terrified to use her call light for assistance during the night. The facility's staff schedule confirmed that the CNA was assigned to Resident #1 during the reported times, and the Director of Nursing confirmed that the cream should not have been applied internally. The facility's administrator acknowledged that the resident had reported the incident but stated that the decision to unsubstantiated the allegation was based on the resident's statement to the police that there was no wrongdoing, attributing the allegation to her past trauma. The CNA was suspended during the investigation but returned to work shortly after. Resident #2 also reported inappropriate behavior by the same CNA. She described the CNA attempting to touch her genitals on two occasions, making her feel afraid. The facility's staff schedule confirmed that the CNA was assigned to Resident #2 during the reported times. The resident's Trauma Informed Assessment indicated that she was very horrified and on guard after the incident. The facility's administrator stated that they offered to have a physician examine Resident #2, but she declined. The CNA was suspended pending the investigation, and the facility filed a state report. The facility's failure to act on the initial report from Resident #1 and to protect Resident #2 from similar behavior indicates a significant lapse in safeguarding residents from abuse. The inaction of the staff, including the failure to report the initial incident and the decision to allow the CNA to continue working with the residents, contributed to the ongoing distress and fear experienced by the residents. The facility's investigation and response to the incidents were inadequate, as evidenced by the return of the CNA to work shortly after the suspension and the reliance on the resident's past trauma to unsubstantiated the allegations.
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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