Casa Real
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Fe, New Mexico.
- Location
- 1650 Galisteo Street, Santa Fe, New Mexico 87505
- CMS Provider Number
- 325038
- Inspections on file
- 35
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 56
Citation history
Health deficiencies cited at Casa Real during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, hypoxia, and other comorbidities was observed receiving oxygen via nasal cannula connected to a portable concentrator without any corresponding physician order specifying when oxygen should be administered. The same resident had a nebulizer with tubing and a mask in the room, and neither the oxygen tubing nor the nebulizer tubing was dated to indicate when they were placed or should be changed. A CNA confirmed the resident was on oxygen and that the undated tubing should have been dated, demonstrating a failure to follow professional standards for respiratory care and oxygen use.
Nursing staff failed to correctly implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a pressure ulcer. During an observed wound treatment, an LPN performed high-contact care without a gown, there was no EBP signage, and PPE was not readily accessible. In interviews, the LPN reported being told that gowns were only required for residents on transmission-based precautions, and the Infection Preventionist confirmed she believed EBP was only needed for infected wounds, reflecting a misunderstanding of EBP requirements for residents with pressure ulcers or wounds.
A resident with sepsis, morbid obesity, an abdominal wound vac, an unstageable sacral pressure ulcer, and an actual infection with a surgical wound did not have required Enhanced Barrier Precautions (EBP) signage posted in the room, and PPE was not readily accessible. During observed wound care, an LPN performed treatment without donning a gown. In interviews, the LPN reported believing gowns were only required for residents on transmission-based precautions, and the IP stated that EBP was only needed for residents with infected wounds, demonstrating a failure to implement EBP and appropriate PPE use during high-contact wound care activities.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
A resident with an indwelling urinary catheter sat in the dining room during breakfast with the urinary drainage bag exposed under the wheelchair and without a dignity cover. A nurse confirmed that the drainage bag was visible and acknowledged that all drainage bags should be covered with a dignity cover, but this one was not, resulting in the resident’s medical device being visible to others and failing to maintain the resident’s dignity.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Improper Disposal of Unused Medications: Two pills were observed in the trash bin attached to the north hall med cart inside an unlabeled medication cup. An RN confirmed the meds were in the trash, and the UM stated unused meds should have been disposed of in the drug buster; controlled meds require two licensed staff and an update to the narcotic count sheet.
Therapeutic diets were not followed for a resident with hypokalemia who was ordered a regular/liberalized pureed diet. During lunch observation, the resident’s meal ticket indicated a pureed diet, but the resident was served whole Mandarin oranges instead of a pureed dessert, and a CNA confirmed the oranges were not pureed.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
A resident with dementia, behavioral disturbance, CKD, and other comorbidities was involved in two separate sexually inappropriate incidents with another resident. After the first incident, the facility generated a written discharge notice citing safety concerns and including appeal information, but key fields such as the discharge planning conference date were left blank and there is no clear evidence the representative actually received it. Following a second similar incident, a second discharge notice was created with an undated 30‑day notice period and no conference date, and the Social Services Director reported sending both notices with the transport driver at the time of discharge. The resident’s spouse stated she was only called and told he had to leave immediately, did not receive any written discharge notice, and was unaware of her appeal rights, demonstrating a failure to provide required written discharge notification to the resident’s representative.
A resident developed a new coccyx pressure ulcer, but neither the provider nor the POA was notified by facility staff. The POA only became aware of the wound after the resident was hospitalized, and the NP responsible for the resident was also not informed. Multiple staff interviews confirmed that required notifications were not made when the pressure ulcer was discovered.
A resident developed a stage two pressure ulcer on the coccyx that was not consistently identified, measured, or documented by nursing staff, despite evidence of its presence and ongoing treatment. Barrier cream was applied multiple times, and CNAs noted redness in the area, but licensed staff failed to properly assess or record the wound's progression. Facility leadership and staff interviews confirmed that required wound care protocols were not followed, resulting in the ulcer being unmonitored and unmeasured.
A resident's shower and refusal records were not consistently documented according to the facility's schedule and policy. Review of the EHR showed multiple missed entries for scheduled showers, with staff confirming that documentation was incomplete and should have been maintained at all times.
A facility failed to update a resident's care plan to reflect the removal of a bathroom door alarm, the use of a fall mat, and an anti-roll back device on the resident's wheelchair. The alarm was removed by an RN who thought it was a restraint, and the care plan lacked documentation for the fall mat and anti-roll back device, which were confirmed by staff to be in use. This oversight could lead to staff being unaware of the resident's care needs.
A facility failed to obtain physician orders for a resident's safety devices, including a bathroom door alarm, fall mat, and anti-roll back device. The Maintenance Manager installed the alarm without an order, and the DON confirmed the absence of orders for these devices. A review of the resident's physician orders showed no documentation for these safety measures.
A facility failed to provide timely foot care for a diabetic resident, resulting in long toenails and delayed podiatry appointments. The resident's daughter reported the issue, and staff interviews confirmed the lack of timely care. The Director of Nursing emphasized the importance of following physician orders for diabetic foot care, but the facility did not ensure timely podiatry appointments, as documented in the resident's records.
A resident's bathroom was found in an unsanitary condition with feces on the floor, a sticky surface, and a foul odor. The handheld shower head was on the floor, and wash bins with dirty cloths were uncovered. A CNA reported ongoing issues with the resident's bathroom cleanliness, while the DON was unaware of the situation. Housekeeping staff indicated that CNAs clean body fluids before they disinfect the area.
The facility's central patio walkway was found to be unsafe due to broken and uneven concrete and brick pavers, posing a fall risk to residents, staff, and visitors. The issue was identified during a tour in October 2024 and reported to the Maintenance Manager, who acknowledged the problem and submitted a repair request, but no repair date was set.
A resident with multiple medical conditions was improperly discharged from a LTC facility to a homeless shelter without medications or care instructions. The facility failed to document the discharge process or communicate with the resident's doctor. The administrator claimed the discharge was due to inappropriate behaviors, but there was no supporting documentation. The resident was later hospitalized with pneumonia.
A facility failed to provide a written discharge notice to a resident and the Ombudsman, resulting in an unplanned and inappropriate discharge. The resident, who was cognitively intact and independent, was taken to a homeless shelter without prior notification. The facility's records lacked documentation of the discharge notice or reasons, and the Ombudsman confirmed no notice was received.
A CNA failed to report a fall involving a resident with a history of muscle weakness, hemiplegia, and dementia. The resident was found partially on the floor, and the CNA attempted to return the resident to bed without assistance. The CNA did not report the fall or the injuries to the nurse, who later observed the resident with visible injuries. The CNA admitted to not reporting the incident, leading to their termination.
A resident with multiple health issues, including cognitive and mobility impairments, was left unsupervised in the bathroom, contrary to their care plan. This led to the resident falling while attempting to call for help, resulting in abrasions. The DON confirmed the expectation that staff should not leave the resident alone, but was unsure of the duration of unsupervised time.
A resident with dementia was left covered in feces after a CNA used abusive language and abandoned their care. LPNs found the resident in a state of neglect, with feces on their body and surroundings. The CNA was not located on the unit after the incident and returned only to continue yelling profanities before leaving again. The facility's administrator confirmed the CNA's inappropriate behavior.
A resident with dementia and Parkinson's disease experienced a decline in health leading to death. A former employee, related to the resident, received unauthorized PHI via text from another former employee, including allegations of abuse by a CNA. The SSD confirmed the incident but denied sharing details, while the Administrator stressed that PHI should only be shared with listed contacts.
A facility failed to report an abuse allegation within the required timeframe. A resident with dementia and Parkinsonism was subjected to loud profane language by a CNA, who admitted to becoming angry and cursing at the resident. The Administrator was informed of the incident the same night, but the report was submitted to the State Agency the next morning, missing the two-hour reporting requirement.
A resident with dementia and hemiplegia suffered a fractured knee due to improper transfer by a CNA, who failed to use a gait belt as per facility training. The resident's feet became tangled during the transfer, causing intense pain. Despite the resident's complaints, the CNA did not report the incident or seek immediate assessment, leading to the resident's injury.
A resident admitted with multiple diagnoses, including high blood pressure, did not receive the prescribed medication losartan until four days after admission due to a failure to enter the order into the medical record. An LPN confirmed this as a medication error, highlighting a lapse in the facility's medication administration process.
The facility failed to prevent and manage pressure ulcers for two residents. One resident's left heel ulcer worsened due to inadequate monitoring and treatment, leading to an amputation. Another resident did not receive regular skin evaluations, resulting in a lack of documentation and oversight of their pressure ulcer. Staffing shortages and inconsistent wound care practices contributed to these deficiencies.
A resident at risk for dehydration due to chronic kidney disease and other conditions did not receive timely IV fluid hydration as ordered by a physician. The facility delayed the administration of IV fluids by five days due to a lack of supplies and staff awareness. Additionally, the resident's fluid intake was inconsistently documented, leading to prolonged dehydration and an untreated UTI. Interviews confirmed the resident's significant thirst and the staff's failure to monitor fluid intake properly.
A resident with a pressure ulcer was discharged without receiving necessary wound care instructions, leading to a worsening condition and subsequent hospitalization. Interviews with staff and the resident's niece confirmed the lack of discharge documentation and communication, resulting in a left below-knee amputation.
A resident with chronic pain and constipation was hospitalized due to fecal impaction after the facility failed to monitor and document bowel movements as required. Despite being on a medication regimen, the resident did not have a bowel movement for several days, and staff did not notify the provider in a timely manner. Interviews revealed a lack of communication and documentation by CNAs and nursing staff.
The facility failed to provide adequate staffing, resulting in residents missing scheduled baths and showers, and being unsupervised during smoking times. This affected residents' hygiene and safety, as confirmed by interviews with staff and the DON.
The facility did not provide bedtime snacks, resulting in a 14.5-hour gap between dinner and breakfast for several residents. Dinner was served at 5:00 PM, and breakfast at 7:30 AM. Residents expressed that they were not given a bedtime snack, and the Dietary Manager confirmed that snacks were left in the nourishment room but not distributed individually. It was unclear if residents were informed about the availability of these snacks.
The facility was found to have several deficiencies in food storage and handling, including unlabeled and undated food containers, an uncovered garbage bin near food prep areas, and a dietary aide not wearing a hair restraint. Additionally, a can of chili con carne was stored on the floor, and the kitchen's back door was propped open, contrary to protocol.
The facility failed to implement an effective infection control program, as observed with uncovered laundry carts and improper disposal of PPE in resident rooms. A housekeeper acknowledged the need for covered carts, and the DON and IP confirmed the lack of PPE bins and liners in trash cans, leading to potential infection risks.
Two residents in a relationship were not provided with a private space despite their requests, leading to frustration and concerns about rule-breaking. Staff interviews confirmed the relationship and the residents' capability to make decisions, but no arrangements for privacy were made, and staff were unaware of any designated space for such purposes.
The facility failed to ensure accurate documentation of advanced directives for three residents, leading to discrepancies between MOST forms, physician orders, and medical records. These inconsistencies could result in residents' medical treatment preferences not being honored.
The facility failed to update care plans for two residents, one requiring oxygen use and another listed for a non-existent restorative nursing program. The first resident's care plan lacked documentation for oxygen use despite a physician's order, while the second resident's care plan included a restorative program that the facility did not offer. These deficiencies were confirmed by facility staff.
The facility failed to provide scheduled showers to four residents, impacting their personal care. A resident with seizures and hemiplegia was not consistently offered showers, leading to feelings of uncleanliness. Another resident, dependent on assistance due to weakness, often received fewer showers than scheduled, with staffing cited as a reason. A third resident, requiring help due to a recent fall, and a fourth resident with dementia, also did not receive the scheduled showers. Staff interviews and documentation confirmed these deficiencies.
The facility failed to provide an ongoing activity program for residents who preferred room visits over group activities. Records and interviews revealed inconsistencies in scheduled room visits, with some residents receiving minimal or no visits despite being scheduled for regular interaction. The Activities Director confirmed the lack of adherence to the planned schedule.
The facility failed to prevent accidents and ensure adequate supervision for three residents. One resident, identified as a fall risk, did not have a fall mat as ordered, and their care plan was not updated. Two other residents, requiring supervision while smoking, were observed smoking unsupervised, and their smoking assessments were not completed quarterly.
A resident with end-stage renal disease, dependent on dialysis, experienced a lapse in communication between the LTC facility and the dialysis center. The facility's Dialysis Communication Book lacked documentation for several dialysis sessions, which was confirmed by an LPN. The DON highlighted the importance of these forms for monitoring the resident's condition, but the Medical Records clerk could not locate the missing documents, indicating a communication breakdown.
The facility failed to provide necessary behavioral health care to two residents. One resident's psychiatric progress notes were not documented in the EHR despite being seen by a provider, and another resident was not referred to a psychiatric services provider as ordered by a physician. Staff interviews confirmed lapses in documentation and follow-up on referrals.
A facility failed to review and consider a pharmacist's recommendations for a resident with multiple diagnoses, including alcoholic cirrhosis and anxiety disorder. The pharmacist advised monitoring for side effects of Risperidone and a dose reduction of Hydroxyzine, but there was no evidence these were reviewed or acted upon. The physician orders did not include monitoring instructions, and the DON could not confirm if the recommendations were addressed.
A facility failed to ensure a resident's PRN psychotropic medication order was reviewed and renewed every 14 days. The resident, with multiple diagnoses including anxiety disorder, had a standing order for Lorazepam. The medication was administered on specific dates, but the order was not reviewed as required, confirmed by the DON.
The facility failed to maintain a safe and sanitary environment for 109 residents. Trash bins were overflowing, cigarette butts littered the patio, and a resident was seen putting them in their mouth. The laundry room had only one leaking washing machine, with standing dirty water, after the other was removed. The DON and a housekeeper confirmed these issues.
A resident requested access to their medical records from the facility's DON but did not receive them, despite several attempts and conversations with the past administration. The current Administrator confirmed that residents should have access to their records at any time.
Failure to Follow Professional Standards for Respiratory Care and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards for one resident with significant respiratory and cardiac conditions. The resident was admitted with systemic lupus erythematosus, morbid obesity, chronic respiratory failure with hypoxia, cor pulmonale, and hypertension. Record review showed a physician order for Ipratropium-Albuterol solution, 3 ml to inhale orally three times a day for seven days for persistent congestion, but there was no physician order for supplemental oxygen specifying when oxygen should be administered. During observation, the resident was seen wearing a nasal cannula connected to a portable oxygen concentrator, and the nasal cannula tubing was not dated. A nebulizer machine was also observed on the resident’s dresser with tubing and a mask, and this tubing was likewise not dated. In an interview, a CNA confirmed that the resident was on oxygen and acknowledged that neither the concentrator tubing nor the nebulizer tubing was dated, and that they should have been dated. These findings demonstrate that oxygen was being used without corresponding medical orders and that oxygen and nebulizer tubing were not changed or tracked in accordance with professional standards.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Nursing staff were not competent in implementing Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, resulting in improper use of personal protective equipment (PPE) during wound care. During an observation of wound care for Resident #1, there was no signage posted indicating that EBP was required, and PPE was not readily accessible for activities of daily living, wound care, or other high-contact resident care activities. Licensed Practical Nurse (LPN) #1 was observed performing wound care for Resident #1 without donning a gown before providing this high-contact treatment. In an interview following the observation, LPN #1 stated she was unaware that gowns were required for all wound care and reported that the Infection Preventionist (IP) had instructed staff that gowns were only needed for residents on transmission-based precautions. In a separate interview, the IP stated that EBP was not needed for all residents with a pressure ulcer or wound and was only required for residents with an infected wound. This demonstrated a lack of understanding by the IP regarding EBP requirements for PPE use, which contributed to the nursing staff’s failure to follow appropriate infection control practices for residents with pressure ulcers or wounds.
Failure to Implement Enhanced Barrier Precautions and PPE for Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and appropriate use of personal protective equipment (PPE) for a resident with significant wounds and infection. The resident was admitted with diagnoses including sepsis, morbid obesity, and a cutaneous abscess of the abdominal wall, and had physician orders for wound care to an unstageable sacral pressure ulcer and for monitoring a wound vac to the abdomen. The resident’s care plan documented risk for skin breakdown, nutritional risk related to multiple diagnoses and wound healing needs, and an actual infection with a surgical wound. During observation of the resident’s room, surveyors noted there was no EBP signage posted and PPE was not readily accessible. Further observation showed that during wound care provided in the resident’s room, an LPN performed the treatment without donning a gown. In interview, the LPN stated she was unaware that gowns were required for all wound care and reported that the Infection Preventionist (IP) had instructed staff that gowns were only needed for residents on transmission-based precautions. In a separate interview, the IP stated that EBP was not needed for all residents with pressure ulcers or wounds, but only for residents with infected wounds. These actions and statements demonstrate that required EBP signage was not posted, PPE was not made readily available, and staff did not implement EBP during high-contact wound care activities for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Maintain Dignity by Leaving Urinary Drainage Bag Uncovered in Dining Area
Penalty
Summary
The facility failed to maintain a resident’s dignity by not ensuring a privacy cover was used on the resident’s urinary drainage bag while the resident was in a public area. During a breakfast observation on 03/24/26 at 9:09 a.m. in the locked unit dining room, Resident #11 was seen sitting in a wheelchair with the urinary drainage bag exposed under the wheelchair and without a dignity cover. Record review showed that the resident had a physician’s order for an indwelling catheter, initiated on 02/01/26, to continuously drain urine from the bladder. In an interview at 9:11 a.m., Registered Nurse #3 confirmed that the resident’s drainage bag was exposed without a dignity cover and stated that all drainage bags should be covered with a dignity cover, acknowledging that this one did not have a cover. This deficiency is likely to result in the resident's medical device being visible to other residents and staff, thereby failing to maintain the resident's dignity.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Improper Disposal of Unused Medications
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when unused medications were found in the trash bin attached to the north hallway medication cart. During observation, two medications were seen inside an unlabeled medication cup in the trash bin: a round blue pill stamped with 61 and an oblong orange pill stamped with 20. RN #1 confirmed the medications were in the trash bin and stated unused medications should be disposed of in the drug buster located in the bottom drawer. The Unit Manager also stated that all unused medications are to be disposed of using the drug buster and that this did not happen; he further stated that controlled medications such as narcotics require two licensed personnel to dispose of them together and to update the narcotic count sheet.
Therapeutic Diet Not Followed for a Resident
Penalty
Summary
Therapeutic diets were not provided as prescribed for R #12. R #12 was admitted with a diagnosis of hypokalemia and the MDS indicated a regular/liberalized pureed diet. During lunch observation on 3/26/26 at 11:42 a.m., R #12's lunch ticket showed a pureed diet, but the resident was served whole Mandarin oranges instead of a pureed dessert. CNA #2 confirmed that the Mandarin oranges were whole and not pureed.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Failure to Provide Proper Written Discharge Notice to Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide proper written notice of discharge to a resident’s representative. The resident in question was admitted with multiple diagnoses including dementia with behavioral disturbance, paroxysmal atrial fibrillation, restlessness and agitation, chronic kidney disease, history of pulmonary embolism, and was receiving palliative care. Following a reported incident on 06/22/25 in which the resident was found on top of another resident with his pants down, attempting to pull down the other resident’s pants and touching her private area, the facility documented a Notice of Intent to Discharge. This notice stated that discharge would be effective 30 days from 06/22/25 due to safety concerns related to the resident’s clinical or behavioral status, and it included appeal contact information. However, the discharge planning conference date was left blank, and the method of delivery was noted only as “verbal and hand deliver,” without clear evidence that the representative actually received the written notice at that time. A second incident was documented on 06/30/25, when a hospice RN reportedly found the same resident in bed with the same female resident, kissing her and attempting to put his hands down her pants, with his pants partially down. Following this, a second Notice of Intent to Discharge was created, again citing safety of individuals in the facility as the reason for discharge. This second notice identified a 30‑day notice period but left the effective date blank and again omitted a specific date for the discharge planning conference. The letter was signed by the Social Services Director and included appeal contact information, with a handwritten note indicating the wife lived two hours away, did not drive, and that the notice was “also hand delivered.” In interview, the resident’s wife stated that she was never told about a planned discharge in advance and that she was only called late in the afternoon and told to come pick him up, which she could not do. She reported that the facility told her they could no longer keep him and that they would send him home, and she confirmed she did not receive a written discharge notice and was unaware she could contest the discharge. She described concerns about her ability to care for him at home and indicated she would have preferred that he remain in the facility. In a separate interview, the Social Services Director stated that the first notice was given to the wife after the first incident and that, after the second incident, the Administrator directed an immediate discharge. The SSD reported that both written notices were sent with the driver to give to the wife when the resident was dropped off, but this conflicts with the wife’s statement that she did not receive written notice, demonstrating the facility’s failure to ensure written discharge notice was provided to the resident’s representative.
Failure to Notify Provider and POA of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the appropriate medical provider and the resident's Power of Attorney (POA) when a new coccyx pressure ulcer was identified in a resident. The pressure ulcer was discovered on the resident's coccyx, but the POA was not informed by the facility and only learned of the condition from the hospital over a month later. Interviews with facility staff, including the Skin Health Lead and the Unit Manager, revealed that neither the provider nor the POA was notified as required when the new pressure ulcer was identified. Further interviews confirmed that the Nurse Practitioner responsible for the resident was also not informed of the new pressure ulcer and was unaware of its existence. The Director of Nursing acknowledged that both the provider and the POA should have been notified immediately upon discovery of the pressure ulcer, but this did not occur. The lack of timely notification was confirmed by multiple staff members and the POA, indicating a breakdown in communication regarding a significant change in the resident's condition.
Failure to Identify, Document, and Monitor Pressure Ulcer
Penalty
Summary
Facility staff failed to provide necessary treatment and services to prevent the development and worsening of a pressure ulcer for one resident. The resident was admitted and later discharged to the hospital, where a stage two pressure ulcer on the coccyx was identified. Facility records showed that the coccyx pressure ulcer was not consistently identified, measured, or documented by nursing staff, despite evidence from wound care supply orders, skin evaluations, and shower sheets indicating the presence of skin damage in the coccyx area. The only documentation of the coccyx pressure ulcer occurred on one occasion, and no measurements were ever recorded to monitor changes in the wound. Nursing staff applied barrier cream to the resident's coccyx pressure ulcer on multiple occasions, as indicated by the Medication Administration Record, but failed to document the presence or progression of the wound. Certified Nursing Assistants also noted redness in the coccyx area on several shower sheets, but this information was not followed up with proper wound assessment or documentation by licensed nursing staff. Interviews with facility staff, including the Skin Health Lead, Unit Manager, and Director of Nursing, confirmed that the expected protocols for wound identification, measurement, and documentation were not followed for this resident. The resident's family was not informed about the presence of the coccyx pressure ulcer, and facility leadership initially denied its existence prior to the resident's hospital transfer. However, interviews with nursing staff confirmed that the wound was present and being treated, albeit without proper documentation or monitoring. The lack of consistent assessment and documentation led to the pressure ulcer being unmonitored and unmeasured, contrary to facility policy and standard care expectations.
Incomplete Shower Documentation for a Resident
Penalty
Summary
The facility failed to ensure that shower documentation was complete and accurate for one resident. Record reviews showed that the resident was scheduled to receive a bath or shower every Monday, Wednesday, and Friday, but there were multiple instances where showers were neither documented as given nor as refused. Specifically, in January, only seven out of twenty-one scheduled showers were documented with no refusals noted; in February, five out of twenty-three were documented with five refusals; and in March, nine out of thirty-one were documented with two refusals. There was no documentation available for the remaining opportunities, and refusals were not consistently recorded in the electronic health record (EHR). Interviews with facility staff, including a CNA, an RN, and the DON, confirmed that showers and refusals should be documented on the resident's shower sheet and in the EHR. Staff acknowledged that the documentation was incomplete and that the required records were not maintained as per facility policy and professional standards. The lack of complete and accurate documentation was confirmed by all interviewed staff members.
Failure to Update Resident Care Plan with Critical Interventions
Penalty
Summary
The facility failed to update a resident's care plan to reflect changes in their care needs and interventions. Specifically, the care plan did not accurately reflect the removal of a bathroom door alarm, the use of a fall mat, and the use of an anti-roll back device on the resident's wheelchair. The bathroom door alarm, initially installed to alert staff when the resident entered the bathroom, was removed by a registered nurse who mistakenly believed it was a restraint. The removal was not documented in the care plan, and there was no order for its placement or removal. Additionally, the care plan lacked documentation for the use of a fall mat, which was intended to prevent injury during a seizure, and an anti-roll back device on the resident's wheelchair, which was meant to prevent falls when the resident attempted to stand up. Interviews with facility staff, including CNAs, the Maintenance Manager, the Director of Nursing, and the Director of Rehab, revealed a lack of awareness and communication regarding these interventions. The staff confirmed the presence and purpose of the fall mat and anti-roll back device, but these were not reflected in the care plan or supported by physician orders. The failure to update the care plan with these critical interventions could lead to staff being unaware of the resident's care needs and preferences, potentially resulting in inadequate care for the resident.
Failure to Obtain Physician Orders for Safety Devices
Penalty
Summary
The facility failed to meet professional standards of quality for a resident by not obtaining physician orders for specific safety measures. The Maintenance Manager installed an alarm on the resident's bathroom door without a physician's order, and the Director of Nursing confirmed that there were no orders for the door alarm, fall mat, or anti-roll back device. A review of the resident's physician orders revealed no active or discontinued orders for these safety devices, indicating a lack of proper documentation and authorization for their use.
Failure to Provide Timely Diabetic Foot Care
Penalty
Summary
The facility failed to provide adequate foot care for a resident with diabetes, as evidenced by the resident's long toenails and the lack of timely podiatry appointments. The resident's daughter reported that her father's toenails were very long and required trimming, and she had requested a podiatry appointment in early December 2024, which had not been scheduled. Interviews with facility staff revealed that the resident was last seen by a podiatric technician on January 16, 2025, for nail care, but there was no documentation available for previous podiatry appointments. Certified Nurse Aides (CNAs) noted the resident's long toenails during showers and documented the need for podiatry care on shower sheets. The Director of Nursing acknowledged the importance of nail care for diabetic residents and stated that physician orders should be followed, and podiatry appointments scheduled timely. Record reviews showed that the resident had physician orders for daily diabetic foot care, including inspection of feet and shoes, and checking pedal pulses. Despite these orders, the facility did not ensure timely podiatry appointments, leading to the resident's long toenails and potential risk for discomfort or infection.
Infection Control Deficiency in Resident's Bathroom
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident, as observed during a survey. The resident's bathroom was found to be in an unsanitary condition, with feces on the floor, a sticky floor surface, and urine present in the toilet. Additionally, the handheld shower head was improperly placed on the bare floor, and wash bins containing dirty washcloths were left uncovered under the bathroom sink. The room and bathroom also emitted a foul odor, indicating a lack of cleanliness and sanitation. Interviews with facility staff revealed further issues contributing to the deficiency. A Certified Nurse Aide (CNA) reported that the resident's bathroom frequently had a foul smell and feces on the floor and walls, due to the resident's habit of taking showers with a brief on and flushing briefs and paper towels down the toilet, causing drain backups. The Director of Nursing (DON) was unaware of the bathroom's condition but confirmed that the observed state was unacceptable. The Housekeeping Director and Housekeeping Account Manager stated that CNAs are responsible for cleaning body fluids, while housekeeping disinfects the areas afterward. Following the observation, the Housekeeping Director instructed an increase in the cleaning frequency of the resident's bathroom.
Unsafe Patio Walkway Poses Fall Risk
Penalty
Summary
The facility failed to maintain a safe and level central patio walkway, which affected all residents using the patio for smoking and other activities. During an observation on January 21, 2025, it was noted that the paved concrete and brick pavers were broken and uneven, with some areas having a 1/2 inch hole and others showing a change in elevation. This condition poses a potential fall risk to residents, staff, and visitors. The Business Office Manager (BOM) reported that during a walking tour with an insurance company observer in October 2024, the patio's condition was identified as a fall risk. The BOM communicated this concern to the Maintenance Manager (MM) immediately after the tour. The MM acknowledged awareness of the issue and stated that a request for repair funds had been submitted, but no repair date was set.
Improper Discharge of Resident to Homeless Shelter
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed in the discharge of a resident, leading to an unsafe and unplanned discharge. The resident, who had been admitted with multiple medical conditions including epilepsy, dysphagia, and a recent myocardial infarction, was transferred to a local homeless shelter without medications or care instructions. The facility did not document the reason for the discharge, the location of the discharge, or any efforts made to meet the resident's needs prior to discharge. Interviews with the New Mexico Council on Aging Case Manager and Housing Specialist, as well as the Homeless Shelter Case Manager, revealed that the resident was left at the shelter without any prior notice or medical documentation. The resident stayed at the shelter for 14 days before being taken to the hospital with pneumonia. The facility's records did not contain any discharge or transfer orders, nor did they document any discharge planning or communication with the resident's doctor. The facility administrator claimed the discharge was at the resident's request due to inappropriate behaviors, but there was no documentation to support this claim. The administrator admitted to driving the resident to the shelter personally and acknowledged that no medical records or medications were provided to the shelter. The facility's Ombudsman and the Homeless Shelter Case Manager both expressed concerns about the appropriateness and planning of the discharge.
Failure to Provide Discharge Notice and Documentation
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident, as well as to the resident's representative and the Ombudsman, which is a requirement for ensuring residents can advocate for their rights. The resident, who was cognitively intact and independent in daily activities, was discharged without any documented order or plan. The facility's records did not contain any documentation of a discharge notice or the reasons for the discharge. The resident was taken to a local homeless shelter without prior notification to the Ombudsman or the resident's representative. The resident stayed at the shelter for 14 nights before being admitted to a hospital for pneumonia. The Ombudsman confirmed that she did not receive any notice of the discharge, and the facility administrator admitted to not providing any notice or documentation regarding the discharge. This lack of communication and documentation led to an unplanned and inappropriate discharge.
CNA Fails to Report Resident Fall and Injuries
Penalty
Summary
A Certified Nurse Aide (CNA) failed to report a fall with injury involving a resident, which was a deficiency identified during a survey. The resident, who had a history of muscle weakness, dysphasia, right-sided hemiplegia following a stroke, hypotension, and unspecified dementia, was at risk for falls due to impaired mobility and poor safety awareness. On the morning of the incident, the CNA found the resident partially on the floor and attempted to return the resident to bed without assistance. The CNA did not report the fall or the injuries sustained by the resident to the nurse on duty. The nurse later observed the resident with visible injuries, including bright red blood from the right upper forearm/elbow area and a swollen contusion on the right upper forehead/temple area. Upon questioning, the CNA admitted to not reporting the fall or the injuries to the nurse, despite being trained to do so. The facility's administrator confirmed the CNA's failure to report the incident, which led to the CNA's termination. The nurse assessed the resident, treated the wounds, and arranged for the resident to be sent out by ambulance.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was free from accidents due to inadequate supervision while using the toilet. The resident, who was admitted with multiple diagnoses including non-traumatic interceder hemorrhage, cerebral edema, cognitive communication deficit, lack of coordination, muscle weakness, and difficulty in walking, required assistance with personal care and was at risk for falls. The care plan specified that staff should offer toileting assistance every two hours and not leave the resident alone in the bathroom. However, the resident was found on the bathroom floor with abrasions after attempting to reach the call string for help, indicating that the staff left the resident unsupervised. During an interview, the Director of Nursing (DON) acknowledged that it was expected that staff should not leave the resident alone in the bathroom, but was unsure of the duration the resident was left unattended. The resident reported being left alone for a long time and attempted to get off the toilet, which led to the fall. This incident highlights a failure to adhere to the care plan, which increased the risk of injury to the resident.
Resident Neglected and Abused by CNA
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when a staff member used loud, foul, abusive language and abandoned the resident instead of providing care. The resident, who had multiple diagnoses including dementia, altered mental status, and hallucinations, was left covered in feces. The incident occurred when a CNA was asked to assist the resident to bed. Instead, the CNA was heard yelling profanities and subsequently left the unit, leaving the resident in a state of neglect. LPNs on duty discovered the resident alone and covered in feces, with some of it dried and on the resident's face, hands, mouth, legs, and body, as well as on the bed, floor, and walls. The CNA responsible for the resident's care was not found on the unit after the incident and returned only to continue yelling profanities before leaving again. The facility's administrator was informed of the incident and confirmed the CNA's inappropriate behavior and abandonment of the resident. Attempts to contact the CNA were unsuccessful.
Unauthorized Disclosure of Resident's PHI
Penalty
Summary
The facility failed to safeguard clinical record information, resulting in the disclosure of private health information (PHI) to unauthorized persons. This incident involved a resident who was admitted with multiple diagnoses, including dementia and Parkinson's disease. The resident experienced a decline in health that led to his death. A former employee of the facility, who was also the resident's daughter-in-law, received a text message from another former employee. The message contained sensitive information about the resident's condition prior to his death, including allegations of possible abuse by a Certified Nurses Aide (CNA) and conjecture about the cause of death. The daughter-in-law contacted the Social Services Director (SSD) to confirm the information, who acknowledged the incident and mentioned that the CNA was suspended. The facility Administrator was aware of the family's concerns about neglect but was unsure how the daughter-in-law was contacted. The Administrator emphasized that resident health care information should only be shared with listed contacts. The SSD confirmed speaking with the daughter-in-law but denied providing details about the incident, although she was aware of it from a staff meeting.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Agency. The incident involved a resident with dementia and Parkinsonism, who was subjected to loud profane language by a CNA. The CNA became angry and frustrated, cursing loudly at the resident before leaving the area and clocking out. The facility's Administrator was informed of the incident between 9:00 pm and 10:00 pm on the day it occurred, but the initial incident report was not submitted to the State Agency until the following morning at 10:34 am, exceeding the mandated reporting window.
Improper Transfer Leads to Resident's Knee Fracture
Penalty
Summary
The facility staff failed to prevent an accident involving a resident who required extensive assistance for activities of daily living due to conditions such as dementia, diabetes, and hemiplegia following a cerebral infarction. The resident, who was cognitively intact, experienced a fractured knee after being improperly transferred by a Certified Nurses Aide (CNA) from a wheelchair to a bed. The resident's care plan specified the need for staff to stand on the weaker left side during assistance, but this was not adhered to during the transfer. The incident occurred when the resident requested a brief change from CNA #1, who expressed frustration due to workload. During the transfer, the CNA lifted the resident without using a gait belt, contrary to the facility's training protocols. The resident's feet became tangled, resulting in intense pain and a subsequent fracture. Despite the resident's complaints of pain, the CNA continued with the brief change and did not report the incident to a nurse or seek immediate assessment. Interviews with other staff members confirmed that the facility's training required the use of a gait belt and proper support of the resident's body to prevent such accidents. The administrator's investigation revealed that CNA #1 admitted to not using the proper technique, leading to the resident's injury. The incident highlights a failure in adhering to established transfer protocols, resulting in harm to the resident.
Medication Administration Error for Resident
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications in accordance with the physician's orders for a resident. The resident was admitted to the facility with multiple diagnoses, including seizures, mood disorder, dysphagia, and a history of transient ischemic attack. The hospital transfer orders indicated that the resident had a past medical history of second-degree atrioventricular block and high blood pressure, with a specific medication order to begin losartan, 50 mg by mouth daily, upon admission. However, upon review of the resident's Medication Administration Record (MAR), it was found that the staff did not administer losartan until four days after the resident's admission. The Licensed Practical Nurse (LPN) confirmed that the order was not entered into the medical record upon admission, resulting in the resident not receiving the medication as prescribed. This oversight was identified as a medication error, indicating a failure in the facility's medication administration process.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure wounds for two residents. For one resident, the facility did not timely identify a new wound, monitor changes, provide daily treatments as ordered, or notify the physician of the wound's worsening condition. This resident was admitted with a risk for pressure ulcers and later developed an unstageable pressure ulcer on the left heel, which was not properly documented or treated, leading to a below-the-knee amputation. The facility's wound care nurse (WCN) acknowledged that the resident's left heel pressure ulcer deteriorated over time, and there was a lack of consistent weekly skin evaluations. The WCN was also required to work the floor due to staffing shortages, which contributed to the oversight. The resident's medical records did not reflect any updates or changes to the wound care orders, and the wound care was not consistently provided as per the physician's orders. For the second resident, the facility failed to complete and document weekly skin evaluations. The resident had an unstageable pressure ulcer on the right heel, and there was a significant gap between skin evaluations conducted by the WCN. The facility's failure to conduct regular skin assessments and document the condition of the resident's wounds contributed to the deficiency.
Removal Plan
- The nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed.
- Nurses will be educated on completion of skin assessments on admission and weekly per schedule.
- Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds).
- Nurses will be educated on wound processes which include the DIMES (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, wound Edge preparation and wound depth), timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds.
- CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes) and stop and watch.
Failure to Provide Adequate Hydration and Timely IV Fluids
Penalty
Summary
The facility failed to ensure adequate hydration for a resident, identified as R #34, who was at risk for dehydration due to chronic kidney disease, hypertension, cognitive impairment, and poly-pharmacy. The resident was dependent on staff for fluid intake and had a physician's order for IV fluid hydration due to hypercalcemia, a suspected UTI, and dehydration. However, the facility did not provide the ordered IV fluids in a timely manner, with a delay of five days from the physician's order. This delay was attributed to the unavailability of IV supplies and the nursing staff's lack of awareness of where to find them. Additionally, the facility did not adequately document and monitor the resident's fluid intake. Records showed inconsistent documentation of the resident's urinary output and fluid intake, with several instances where no fluid intake was recorded. Interviews with staff and the resident's husband confirmed that the resident experienced significant thirst and that staff failed to document fluid intake consistently. The Director of Nursing acknowledged that the nursing staff did not follow the expected procedures for administering IV fluids and tracking fluid intake, contributing to the resident's prolonged dehydration and untreated UTI.
Failure to Provide Discharge Instructions for Wound Care
Penalty
Summary
The facility failed to provide a discharge summary and post-discharge plan of care for a resident with a pressure wound. The resident, who had a left heel pressure ulcer, was discharged to live with her niece without receiving wound care instructions. The facility's records show that the wound care nurse documented the ulcer's measurements, but there was no documentation of wound care instructions being given to the resident prior to discharge. This lack of communication and documentation likely contributed to the worsening of the resident's condition. Upon discharge, the resident's condition deteriorated, leading to an emergency room visit where the ulcer was found to be non-healing with signs of infection. The resident subsequently underwent a left below-knee amputation. Interviews with the resident, her niece, the social services director, the wound care nurse, and the director of nursing confirmed that the necessary discharge instructions and care plans were not provided, highlighting a significant lapse in the facility's discharge procedures.
Failure to Monitor and Document Bowel Movements Leads to Hospitalization
Penalty
Summary
The facility failed to ensure proper monitoring and intervention for a resident experiencing constipation, which led to the resident being hospitalized with fecal impaction and abdominal pain. The resident, who had a history of chronic pain and constipation, was on a regimen of medications including sennosides docusate sodium, Colace, and glycoLax powder. Despite these medications, the resident did not have a bowel movement for several days, and staff failed to document bowel movements on multiple occasions. The care plan required daily monitoring and documentation of bowel movements, with alerts to nursing staff if no bowel movement occurred in three days, but this was not adhered to. Interviews with staff revealed a lack of communication and documentation regarding the resident's bowel movements. Certified Nursing Assistants (CNAs) were responsible for monitoring and documenting bowel movements and notifying nursing staff if there were issues, but this did not occur consistently. The Physician's Assistant was only notified of the constipation on the day the resident was sent to the emergency room, indicating a failure in timely communication. The Director of Nursing confirmed that the nursing staff should have been monitoring the electronic health record for bowel movement documentation and should have notified the provider about the ineffective medication regimen.
Staffing Shortages Lead to Missed Care and Safety Concerns
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of all 109 residents, resulting in several deficiencies. Residents were not offered baths or showers as scheduled, impacting their personal hygiene and comfort. For instance, one resident, who required assistance due to conditions such as seizures, epilepsy, and hemiplegia, was only offered or given a bath or shower on a few occasions out of the scheduled opportunities. Another resident, dependent on staff for activities of daily living, also missed several scheduled showers, leading to feelings of discomfort and dissatisfaction. Interviews with staff, including CNAs and the Director of Nursing, confirmed that staffing issues contributed to these missed care opportunities. Additionally, the facility failed to supervise residents during designated smoking times, which is a safety concern. One resident, who required supervision while smoking, was observed smoking unsupervised in the courtyard. This lack of supervision was attributed to staffing challenges, as confirmed by interviews with an LPN and the Director of Nursing. Another resident, who was assessed to smoke independently, was also observed smoking without staff presence, contrary to the care plan that required supervision for safety. These deficiencies highlight the facility's inability to maintain adequate staffing levels to ensure the safety and well-being of its residents. The lack of sufficient staff led to missed showers and unsupervised smoking, both of which are critical to maintaining resident safety and comfort. The Director of Nursing acknowledged these issues, confirming that residents were not offered the necessary care and supervision due to staffing constraints.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to provide residents with a nourishing bedtime snack, resulting in more than 14 hours between the evening meal and breakfast for six residents. Dinner was served at 5:00 PM, and breakfast at 7:30 AM, creating a 14.5-hour gap between meals. During an interview with the Resident Council, residents expressed that they were not given a bedtime snack and noted that snacks were previously available but had been discontinued. The Dietary Manager confirmed that snacks were not distributed individually to residents but were left in the nourishment room for those who requested them. However, it was unclear if nursing staff informed residents about the availability of these snacks.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain proper food storage and handling practices, as observed during a kitchen inspection. Unidentified food storage containers in the refrigerator were not labeled or dated, and a large garbage bin was uncovered and placed next to the food preparation table. Additionally, a one-gallon plastic jug of salsa was left open to the air in the walk-in refrigerator, and a tray of cake was found unlabeled and undated. These practices were not in accordance with professional standards and could potentially lead to foodborne illnesses. Further observations revealed that a dietary aide was serving lunch without wearing a hair restraint, and a can of chili con carne was improperly stored on the bare floor in the dry storage area. The back door of the kitchen was also propped open, which is against the facility's protocol. Interviews with staff confirmed these practices were inappropriate, as the dietary manager acknowledged that doors should remain closed and trash cans should be covered in the food preparation area.
Inadequate Infection Control Practices in Facility
Penalty
Summary
The facility failed to maintain and implement an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, during an observation, a housekeeper was seen pushing a rolling rack of clothing down the hallway with only the top part covered, leaving the clean clothing on the bottom exposed. The housekeeper acknowledged that the clothing rack needed to be fully covered, indicating a lapse in adherence to infection control protocols. Secondly, observations in resident rooms 101, 105, and 116 revealed that trash cans were filled with used personal protective equipment (PPE) but lacked liners, and there were no designated PPE bins for staff to properly doff PPE. Interviews with the Director of Nursing and the Infection Preventionist confirmed these findings, with the latter mistakenly believing that resident trash bins could be used for PPE disposal. This misunderstanding and lack of proper equipment in the rooms contributed to the facility's failure to adequately manage infection control measures.
Failure to Accommodate Resident Privacy and Choice
Penalty
Summary
The facility failed to promote resident self-determination by not accommodating the choice of two residents to have privacy with each other. Both residents expressed their desire for private time, including napping together, but reported that the facility had not provided a private space despite previous assurances. Interviews with the residents revealed their frustration and concern about breaking rules, as they were told a private place would be provided upon request. The Social Services Director confirmed that the residents had requested a private space over a month prior, but no arrangements had been made. Staff interviews indicated a lack of awareness or action regarding the residents' requests for privacy. Several staff members, including CNAs and a nurse practitioner, acknowledged the relationship between the residents and their capability to make decisions about their relationship. However, they confirmed that the residents were not allowed to be alone in each other's rooms, and there was no known designated space for privacy. The residents' cognitive abilities were assessed as stable, supporting their capacity to make such decisions, yet the facility did not facilitate their choice for privacy.
Discrepancies in Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that the advanced directives of residents were accurately documented and matched across various records, leading to discrepancies in the medical records of three residents. For Resident #86, there was a mismatch between the MOST form, which indicated Full Code, and the physician's order and facesheet, which indicated Do Not Resuscitate (DNR). This inconsistency was confirmed by the MDS Coordinator during an interview. Similarly, Resident #100's advanced directive was missing from the medical record, and there was no code status documented in the medical chart, despite the facesheet and physician's order indicating Full Code. For Resident #114, there was a discrepancy between the advanced directive, which stated Full Code, and the physician's order and facesheet, which indicated DNR. The MDS Coordinator confirmed that the advanced directive needed to be updated to reflect the current DNR status. These inconsistencies in the documentation of advanced directives could lead to situations where residents' wishes regarding medical treatment are not honored, particularly in emergencies when they are unable to make decisions themselves.
Care Plan Deficiencies for Oxygen Use and Restorative Nursing
Penalty
Summary
The facility failed to update the care plan for two residents, leading to deficiencies in addressing their care needs. For the first resident, the care plan did not include the use of oxygen, despite a physician's order dated 08/19/23 indicating the need for oxygen. The resident was observed wearing oxygen during an interview, and the Minimum Data Set Coordinator acknowledged that the oxygen use should have been included in the care plan but was not. For the second resident, the care plan included a restorative nursing program as an intervention for fall risk, despite the facility not having such a program. The Director of Nursing confirmed that the care plan was outdated and should have been revised to reflect the current services available. These oversights in care planning could result in the residents' care and needs not being adequately addressed.
Deficiency in Providing Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL), specifically in offering and providing baths and showers, to four residents. Resident #41, who requires assistance due to conditions such as seizures, epilepsy, and hemiplegia, was not consistently offered the scheduled three baths/showers per week. Documentation revealed discrepancies in the number of showers provided, and the resident reported feeling unclean due to missed showers. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed the resident was not offered the required number of showers. Resident #50, dependent on assistance for ADL care due to weakness and impaired mobility, was scheduled for two showers per week but often received only one. The resident expressed dissatisfaction with the infrequent showers, and staff interviews corroborated the issue, citing staffing as a reason for missed showers. The DON acknowledged the deficiency, stating that staffing should not have been a barrier to providing the necessary care. Resident #69, who requires assistance due to a recent fall and other health issues, was not consistently offered the scheduled two showers per week. Documentation showed inconsistencies in the number of showers provided, and the resident expressed a desire for more frequent showers. Similarly, Resident #71, at risk for decreased ability to perform ADLs due to dementia, was not offered the scheduled showers, as confirmed by a grievance from the resident's daughter and the DON. The facility's failure to adhere to the shower schedule for these residents highlights a deficiency in providing essential personal care.
Failure to Provide Ongoing Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program for four residents who were reviewed for activities. These residents, who preferred not to participate in group activities, were supposed to receive room visits from activity staff three times a week for social interaction. However, the records show that these visits were not consistently conducted. For instance, one resident had only two room visits out of 13 opportunities in April, and none in June, despite being scheduled for regular visits. Another resident had only one documented room visit in April and none in June, with no activity attendance logs available for review in June. Interviews with the residents and the Activities Director confirmed the lack of scheduled room visits. One resident expressed a desire to engage more with activities such as watching TV, using an iPad, and socializing with others, indicating that the staff did not facilitate these opportunities often enough. The Activities Director acknowledged that the residents who did not attend group activities were supposed to have room visits three times a week, but these visits were not being conducted as planned.
Failure to Prevent Accidents and Ensure Supervision
Penalty
Summary
The facility failed to ensure that three residents were free from accidents and hazards due to staff inaction. For one resident, a fall risk assessment was not completed, and a fall mat was not placed as per physician orders. This resident was identified as a fall risk due to cognitive loss, lack of safety awareness, impaired mobility, pain, and polypharmacy. Despite these risks, the resident's care plan was not updated quarterly, and the necessary fall mat was absent during an observation. Additionally, two residents who required supervision while smoking did not receive the necessary oversight. Smoking assessments for these residents were not completed quarterly as required. Observations revealed that these residents were smoking unsupervised in the courtyard, contrary to their care plans which stipulated supervision. Staff interviews confirmed the lack of supervision during smoking times and acknowledged the failure to conduct timely smoking assessments.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with a dialysis center for a resident requiring dialysis services. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had a physician's order to attend dialysis sessions three times a week. However, the facility's Dialysis Communication Book was missing communication forms for several dates, indicating a lack of documentation regarding the resident's dialysis procedures and results. This lack of documentation was confirmed by a Licensed Practical Nurse (LPN) who noted the importance of these forms for monitoring the resident's status before and after dialysis treatments. Interviews with facility staff, including the LPN and the Director of Nursing (DON), revealed that the communication forms were intended to be completed by facility staff and returned by the dialysis center with post-treatment vitals. Despite this protocol, the Medical Records clerk was unable to locate the missing forms. The DON emphasized the necessity of these forms for understanding any current issues or lab needs for the resident. The absence of these forms suggests a breakdown in communication between the facility and the dialysis center, potentially impacting the resident's care.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident with behavioral health concerns received necessary care by not documenting psychiatric progress notes in the resident's Electronic Health Record (EHR). The resident was admitted with a psychiatric disorder and had a care plan that required referral to a behavioral health specialist. Although the resident was seen by a psychiatric provider on multiple occasions, the facility did not have the updated progress notes in the EHR. Interviews with staff confirmed that the facility had not established a method to receive and document these notes, despite multiple attempts by the psychiatric provider's Human Resources Director to send them. Additionally, the facility did not refer another resident to a psychiatric services provider as per physician orders. This resident, diagnosed with anxiety and depression, expressed feelings of depression and confirmed not having spoken to a psychiatric provider. The Social Services Director stated that a referral was sent via the provider's website but admitted to not following up on the referral. The Director of Nursing confirmed that the referral should have been sent and followed up on, as per the physician's orders.
Failure to Review Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations were reviewed and considered each month for a resident with multiple diagnoses, including alcoholic cirrhosis of the liver, alcohol dependence, anxiety disorder, and repeated falls. The pharmacist recommended monitoring the resident for involuntary movements due to the use of Risperidone, a medication that can cause such side effects. However, there was no indication that this recommendation was reviewed or acted upon by the facility or the healthcare provider. Additionally, the physician orders did not include any directive to monitor the resident for side effects related to Risperidone. Furthermore, the pharmacist suggested a gradual dose reduction of Hydroxyzine, another psychotropic medication prescribed for anxiety. This recommendation also lacked evidence of review or consideration by the facility or provider. The physician orders continued to prescribe Hydroxyzine without any adjustments or monitoring instructions. During an interview, the Director of Nursing, who was not employed at the facility during the time of the recommendations, could not confirm whether the pharmacist's suggestions had been reviewed, considered, rejected, or ordered.
Failure to Review PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident's prescription for a PRN psychotropic medication was reviewed and renewed every 14 days by the prescriber. This oversight involved a resident who was admitted with multiple diagnoses, including alcoholic cirrhosis of the liver, alcohol dependence with alcohol-induced disorder, anxiety disorder, and repeated falls. The resident had a physician's order for Lorazepam, an anti-anxiety psychotropic medication, to be administered as needed for increased anxiety with manic episodes. The Medication Administration Record (MAR) indicated that Lorazepam was administered on specific dates in March and June, but not in April or May. During an interview, the Director of Nursing confirmed that the standing order for Lorazepam should have been reviewed and renewed every two weeks, but this had not occurred as required. This deficiency could lead to residents receiving medications without regular review or oversight, potentially causing over-sedation and other negative side effects.
Facility Environment and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for its 109 residents, as evidenced by several observations and interviews. Trash bins were not emptied regularly, leading to overflowing bins with contents spilling onto the ground. This included three large trash bins and an extra-large bin with mattresses placed beside it. Additionally, cigarette butts were found on the facility's patio area, and a resident was observed picking up and putting cigarette butts in their mouth. The Director of Nursing confirmed the issue with the overflowing trash bins, stating they should be emptied twice a week. In the laundry room, the facility had only one functioning washing machine, which was leaking and surrounded by standing dirty water. The other washing machine was broken and had been removed without replacement. A housekeeper confirmed the unsanitary conditions, noting the need for two washing machines and the presence of standing water. These deficiencies in maintaining cleanliness and functionality could potentially affect all residents and staff, increasing the risk of infection and illness.
Failure to Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to their medical records upon request, which is a violation of the resident's rights. The resident, who is responsible for himself, was admitted to the facility on an unspecified date. He requested a copy of his medical records from the facility's Director of Nursing approximately two months prior to the survey date but had not received them by the time of the interview. The resident had made several attempts to obtain his records through conversations with the past administration. During an interview, the current Administrator, who was not employed at the time of the request, confirmed that residents should have access to their medical records at any time.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
