Clayton Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clayton, New Mexico.
- Location
- 419 Harding Street, Clayton, New Mexico 88415
- CMS Provider Number
- 325100
- Inspections on file
- 16
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Clayton Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the vaccine refrigerator temperature logs in the medication storage room were not completed on numerous dates across both day and night shifts, with large gaps in documentation over many months. An LPN acknowledged that the vaccine fridge temperature log was not being done routinely, despite nurses being responsible for all temperature logs. The DON confirmed that refrigerator temperatures were expected to be checked once per shift and recorded on the log, but this monitoring and documentation did not consistently occur.
Surveyors found that food service sanitation practices were deficient when a plate warmer used for clean dishes contained dried food particles, dried liquid splashes, and trash, and the stove and oven used for meal preparation were visibly soiled with dried food, liquid splashes, dirt, grease, and baked-on food stains. The DM acknowledged that the condition of the plate warmer, stove, and oven was dirty and did not meet his expectations, affecting food preparation and service for all residents.
Surveyors found that the facility failed to consistently implement its infection prevention and control program. A resident on Enhanced Barrier Precautions (EBP) received direct care from two CNAs who did not don required PPE despite EBP signage on the door. In a separate incident, a resident on EBP was transferred with a mechanical lift, and after completing care and removing PPE, CNAs moved the lift directly to another room without cleaning or disinfecting it. The CNAs later acknowledged they had not followed protocol, and the DON, serving as Infection Preventionist, stated that staff are expected to perform hand hygiene, follow infection control precautions, and clean and disinfect all medical equipment after each use.
Staff administered medications to several residents in the dining area during mealtimes, requiring residents to stop eating to take medication cups and receive eye drops from an LPN. Overhead paging announcements were made in the dining area on multiple mornings to reach an LPN, and kitchen serving-area ceiling vents were observed to be covered with dust and dirt, discoloring the vents and surrounding ceiling. These actions and conditions did not support a safe, clean, comfortable, and homelike environment for residents during meals.
Surveyors found that MDS assessments were not accurately completed for three residents. One resident receiving Nitrofurantoin for UTI prophylaxis did not have antibiotic use captured on the MDS, as confirmed by the MDS coordinator. Another resident with COPD and dementia, who had an order for PRN oxygen and an oxygen concentrator at the bedside, had no oxygen use documented on the MDS, which the DON acknowledged was inaccurate. A third resident with multiple comorbidities and a documented diagnosis of ankle edema was observed with red, swollen legs and ankles, yet the MDS did not reflect ankle edema, and the DON confirmed this omission.
Surveyors found that care plans for two residents were not updated to reflect current medical needs. One resident with COPD and other chronic conditions had a physician order for PRN oxygen at 2 L/min via nasal cannula, but this oxygen use was not included in the care plan, as confirmed by the DON. Another resident with multiple neurologic and urologic diagnoses, as well as wasting disease and sarcopenia, was observed with red, swollen ankles and legs; a physician note documented ankle edema, yet the care plan did not address this condition, which the DON acknowledged was missing.
A resident admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order for PRN O2 at 2 L/min via nasal cannula for respiratory distress, but this treatment was not included on the baseline care plan completed at admission. Record review showed the baseline care plan lacked any indication that the resident used O2 as needed, and the DON confirmed that the resident does utilize PRN O2 and that this omission was incorrect.
A resident with chronic respiratory failure, COPD, OSA, emphysema, and MRSA carrier status had a physician order for supplemental O₂ at 2 L/min that did not specify the frequency of administration. The resident was observed in bed using a nasal cannula connected to an O₂ concentrator, and the DON acknowledged that the order lacked required frequency details. This omission in the oxygen order was identified during survey review as a failure to provide respiratory care in accordance with professional standards.
The facility failed to meet the nutritional needs and preferences of residents by not serving the menu items as planned and not providing alternate meal options. During a dinner observation, residents were served Jell-O instead of cheesecake, and the meatloaf lacked glaze due to missing ingredients. Staff interviews revealed that the kitchen did not have the necessary supplies, and residents were not informed of the menu changes. Additionally, no alternate meals were offered, contributing to the deficiency.
The facility failed to properly label and store food items in the Dietary Department, leading to potential cross-contamination risks. Observations revealed multiple unlabeled and undated food items, including containers with unidentified substances, open bags of food, and uncovered pans. The Healthcare Group Services Operationalist confirmed that staff are expected to label and date all items, which should be covered and not open to air. This deficiency could impact all 30 residents consuming food from the kitchen.
The facility failed to notify residents of the outcomes of their grievances, as grievance forms lacked documentation of investigation steps, findings, and corrective actions. Interviews revealed that the Resident Council was not always informed about grievance findings, and the Administrator acknowledged incomplete grievance forms.
A facility failed to conduct required quarterly care plan meetings for a resident, resulting in an outdated care plan. The resident, admitted earlier, had his last care plan meeting in April 2024. He reported not recalling recent meetings, and the MDSC confirmed the oversight, acknowledging the missed meetings.
The facility failed to provide prescribed Restorative Nursing Program (RNP) services to two residents, impacting their ability to perform activities of daily living (ADLs). One resident was supposed to receive RNP services for passive range of motion exercises to both arms, but these were provided only once in September and not at all in October. Another resident was to receive RNP services for upper and lower extremities, but the sole Restorative Aide was unable to deliver these services due to other duties. The Director of Nursing confirmed the lack of service delivery.
The facility did not implement enhanced barrier precautions for residents with wounds or urinary catheters, as PPE was not available outside their rooms and staff were observed providing care without PPE. This oversight was due to a lack of awareness of updated guidelines by the staff.
The facility failed to obtain current signed Influenza Vaccine Informed Consent Forms for residents who received the flu vaccine. Interviews and record reviews revealed that five residents did not have the necessary consent documentation in their medical records. The LVN stated that residents signed the ICF annually, leading to missing consents for the recent vaccinations.
A resident with decreased mobility due to a stroke was unable to reach their call light, which was placed on a chair behind their bed. This oversight left the resident anxious and unable to request assistance for basic needs. Staff interviews confirmed the call light should have been within reach.
A resident reported dissatisfaction with the food served, noting burnt macaroni salad and peach cobbler with salt instead of sugar. The Food Service Director acknowledged these issues, attributing them to new dietary staff requiring supervision. A grievance form confirmed the resident's complaints, highlighting problems with food preparation.
Failure to Routinely Monitor and Document Vaccine Refrigerator Temperatures
Penalty
Summary
Surveyors identified a deficiency related to the storage and monitoring of medications in the facility’s locked medication storage room, specifically the vaccine refrigerator. During an observation on 02/10/26 at 12:55 pm, the vaccine fridge temperature log for January 2025 through February 2026 was found to be incomplete. Numerous dates on the day shift log were left blank, including extended periods such as 01/01/25 through 01/18/25, 01/20/25 through 06/01/25, 06/03/25 through 07/23/25, 07/25/25 through 09/12/25, 09/15/25 through 09/31/25, and multiple additional gaps through 02/08/26. The night shift log also contained multiple missing entries on specific dates throughout 2025, indicating that temperatures were not consistently documented as required. In an interview on 02/10/26 at 12:56 pm, an LPN confirmed that the vaccine medication fridge temperature log was not being completed routinely and stated that nurses are responsible for completing all temperature logs. On 02/11/26 at 1:38 pm, the DON further confirmed there had been inconsistency with checking the vaccine fridge temperature log. The DON stated that the fridge temperature should be checked once per shift and documented on the appropriate log, and acknowledged that this did not occur as required.
Unsanitary Storage of Dishes and Unclean Cooking Equipment in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food service sanitation when kitchen staff failed to properly store dishes and maintain clean cooking equipment. During a random kitchen observation, the plate warmer, which is intended to hold clean plates ready for meal service, was found to contain dried food particles, dried liquid splashes, and trash. The stove was observed with dirty, dried food particles and dried liquid splash marks on the front, and dirt and grease covering the back. The oven interior had baked-on food stains throughout. The Dietary Manager confirmed that the plate warmer, stove, and oven were dirty and did not meet his expectations. These conditions were present in an area used to prepare and serve food for all 36 residents listed on the census provided by the Administrator, indicating that food was not being prepared and served under sanitary conditions as required by professional standards.
Failure to Implement EBP PPE Use and Disinfection of Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement an ongoing infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and proper use of personal protective equipment (PPE). On the 200 hall, a resident with an EBP sign posted on the door was observed receiving direct care from two CNAs who did not wear any PPE while in the room. One CNA was already in the room without PPE, and the second CNA entered the room, closed the door, and provided direct care without donning PPE. After approximately five minutes, both CNAs assisted the resident out of the room in a wheelchair. In a subsequent interview, one of the CNAs confirmed that both were providing direct care to the resident, acknowledged that neither wore PPE, and stated they should have done so. The deficiency also includes failure to clean and disinfect shared resident-care equipment between uses. A resident on EBP was transferred from a wheelchair to a bed using a mechanical lift, and staff providing direct care appropriately donned mask, gown, and gloves. After completing the brief change, the CNAs removed their PPE, performed hand hygiene, and immediately took the mechanical lift to another room without cleaning or sanitizing it. In an interview, both CNAs confirmed they did not follow protocol by failing to clean the mechanical lift after use and stated that all medical equipment is supposed to be wiped down with bleach after each use. The DON, who serves as the facility’s Infection Preventionist, stated that all nursing staff are to perform hand hygiene before and after patient care and follow all infection control precautions, and that all medical equipment is to be cleaned and disinfected after each use.
Medication Administration and Environmental Issues in Dining and Kitchen Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when staff administered medications in the dining area during mealtimes, used an overhead paging system in the dining area, and did not maintain clean kitchen vents. During a lunch meal observation, one resident was seated and eating when an LPN approached, handed the resident a medication cup, and then administered eye drops before the resident resumed eating. Two other residents who were seated and eating at their respective tables were also approached by the same LPN, given medication cups, and stopped eating their meals to take their medications. In an interview, the LPN stated that she usually administers medications in common areas and during mealtimes because that is where all the residents are. Additional observations showed that the overhead paging system was used in the dining area on two separate mornings to call an LPN to contact another staff member. A separate observation of the kitchen serving area revealed that the ceiling vents were covered with dust and dirt, causing portions of the vents and surrounding ceiling to appear brownish-black instead of their intended white color. These conditions were identified as contributing to the failure to maintain a sanitary and homelike environment for residents who eat their meals in the dining area.
Inaccurate MDS Assessments for Antibiotic Use, Oxygen Therapy, and Edema
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in omissions of current clinical conditions and treatments. For one resident with type 2 diabetes mellitus, traumatic brain injury, quadriplegia, obstructive and reflux uropathy, and a need for assistance with personal care, the record showed a physician’s order for Nitrofurantoin 100 mg for UTI prophylaxis. However, review of this resident’s MDS dated [DATE] showed that antibiotic use was not checked, and the MDS Coordinator confirmed during interview that the resident was currently taking an antibiotic and that she failed to capture this on the assessment. Another resident with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and hypertension was observed with an oxygen concentrator at the bedside, and physician orders documented oxygen at 2 L/min via nasal cannula as needed for respiratory distress. The resident’s MDS dated [DATE] contained no indication of oxygen use, and the DON confirmed the resident does utilize oxygen as needed and that the MDS was not accurate. A third resident with Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia was observed asleep in a wheelchair with red, swollen legs and ankles. A physician progress note documented a diagnosis of ankle edema, but the MDS dated [DATE] did not indicate ankle edema. The DON confirmed that this resident does have ankle edema and that the MDS assessment was not accurate.
Failure to Accurately Reflect Oxygen Use and Ankle Edema in Resident Care Plans
Penalty
Summary
Surveyors identified a failure to develop and implement accurate, comprehensive care plans for two residents. One resident with COPD, Alzheimer's disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order dated 08/05/25 for oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of this resident's care plan dated 08/04/25 showed no indication that the resident utilized oxygen as needed. During an interview on 02/13/26 at 9:20 am, the DON confirmed that the resident does use oxygen as needed and acknowledged that the care plan does not indicate this and that it should. For another resident with diagnoses including Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia, surveyors observed the resident asleep in a wheelchair in the dining area on 02/10/26 at 10:30 am, with legs and ankles appearing red and swollen. Record review showed a physician progress note dated 08/21/24 documenting a diagnosis of ankle edema. However, the resident's care plan revised on 07/31/25 contained no indication of ankle edema. In an interview on 02/13/26 at 9:30 am, the DON confirmed that the resident does have ankle edema and stated that the resident's care plan did not meet her expectations because it should include the ankle edema and does not.
Baseline Care Plan Omitted PRN Oxygen Order for Newly Admitted Resident
Penalty
Summary
The facility failed to create an accurate baseline care plan for a newly admitted resident by omitting an essential treatment order. Record review showed the resident was admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN. Physician orders dated 08/05/25 directed that the resident receive oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of the resident’s baseline care plan dated 08/04/25 revealed no indication that the resident utilized oxygen as needed, despite this active order. In an interview, the DON confirmed that the resident does use oxygen PRN and acknowledged that the baseline care plan did not reflect this need and that it should have been included. This discrepancy between the physician’s oxygen order and the baseline care plan content constituted the identified deficiency in accurately capturing the minimum healthcare information necessary to properly care for the resident immediately upon admission.
Incomplete Oxygen Order for Resident with Chronic Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a physician’s order for supplemental oxygen included the frequency of administration. A resident admitted with chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, emphysema, and MRSA carrier status had a physician order dated 09/14/25 for supplemental oxygen at 2 L/min, but the order did not specify how often or under what circumstances the oxygen should be administered. During observation on 02/10/26, the resident was seen in bed wearing a nasal cannula connected to an oxygen concentrator at the bedside. In an interview on 02/13/26, the DON confirmed that the oxygen order should indicate the frequency of administration and acknowledged that it did not, resulting in incomplete respiratory care orders for this resident. The survey findings state that this failure to specify oxygen frequency in the medical order was identified for 1 of 3 residents reviewed for respiratory care and was likely to result in residents receiving too much or not enough oxygen, which could lead to worsening of their conditions.
Failure to Meet Nutritional Needs and Menu Adherence
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of all 30 residents as listed on the facility census. During a dinner observation, it was noted that the staff did not serve the food items as listed on the menu. Specifically, residents were served Jell-O with whipped topping instead of the French orange cheesecake that was on the menu, and the meatloaf served did not have the glaze as indicated. Interviews with staff, including an LPN and the Dietary Manager, revealed that the kitchen did not have the necessary ingredients for the cheesecake or the glaze for the meatloaf due to a delay in the food order. Residents expressed their dissatisfaction with the substitutions and confirmed they were not informed of the menu changes. Additionally, the facility did not provide an alternate meal menu to the residents. The Dietary Manager admitted that no alternate meals were made or offered, citing low census and minimal alternate requests as reasons. The Registered Dietitian confirmed that the posted menu should include alternate menu choices and that the meals served should match the posted menus. The lack of alternate meal options and failure to serve the menu items as planned contributed to the deficiency in meeting the residents' nutritional needs and preferences.
Failure to Properly Label and Store Food
Penalty
Summary
The facility failed to store food in a manner that prevents cross-contamination, as observed in the Dietary Department's refrigerators and freezers. Several food items were found unlabeled and undated, including a four-quart plastic container with an unidentified substance, two five-pound bags of slightly black colored stalks, a two-inch pan of red liquid, a six-quart plastic container of unidentified food, and a tray of 6 oz. glasses of yellow liquid. Additionally, a ten-pound bag of frozen diced chicken, two one-pound bags of beef patties, two one-pound bags of boiled eggs, two ten-pound rolls of Provolone cheese, and a fifty-pound bag of bread crumbs were open to air and not dated. A four-inch soiled steel pan with a two-ounce scoop containing crusted, crumbly food was also found open to air and not labeled or dated. During an interview, the Healthcare Group Services Operationalist stated that it was expected for staff to label and date all items, and they should be covered and not open to air. These failures have the potential to result in cross-contamination, the growth of foodborne pathogens, and foodborne illness, affecting all 30 residents who consume food from the kitchen.
Failure to Notify Residents of Grievance Resolutions
Penalty
Summary
The facility failed to notify four residents of the outcomes or resolutions of their grievances, as revealed through record review and interviews. The grievance log showed that grievances filed by residents regarding issues such as clothing not being changed, snacks being thrown out, cold air from the air conditioner during meal times, a missing candy dish, and a CNA talking on the phone during a shower were marked as resolved. However, the grievance forms lacked documentation of the steps taken to investigate, summaries of findings, confirmation of the grievances, corrective actions, or the issuance date of the written decision. Interviews with the Resident Council and the Administrator further highlighted the deficiency. The Resident Council stated that they were not always informed about the facility's findings regarding their grievances. The Administrator admitted that staff did not complete the grievance forms properly, which resulted in residents not being informed of the resolutions of their grievances.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to revise the care plan for a resident due to the absence of quarterly care plan meetings as required. The resident was admitted to the facility on an unspecified date, and the last care plan meeting was documented on April 30, 2024. During an interview on October 28, 2024, the resident expressed that he did not recall having a care plan meeting recently. Furthermore, the Minimum Data Set Coordinator (MDSC) acknowledged on October 30, 2024, that she was responsible for scheduling and conducting these meetings and confirmed that the resident had missed his last two quarterly care plan meetings.
Failure to Provide Restorative Nursing Program Services
Penalty
Summary
The facility failed to maintain the ability of two residents to perform activities of daily living (ADLs) due to inadequate provision of Restorative Nursing Program (RNP) services. Resident #6 was admitted to the facility and had physician orders for RNP services two to three times a week for passive range of motion exercises to both arms. However, documentation revealed that these services were provided only once in September and not at all in October. Interviews with the resident, a Restorative Certified Nursing Assistant (RCNA), a Certified Nursing Assistant (CNA), a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that the resident did not receive the prescribed RNP services, which were intended to give him a sense of purpose and enjoyment. Similarly, Resident #25 was admitted with physician orders for RNP services three times a week for passive range of motion exercises to the upper and lower extremities. The RCNA, who was the only Restorative Aide in the facility, stated that he was often occupied with other duties, such as working on the floor and transporting residents, which prevented him from providing the necessary RNP services to Resident #25. The DON confirmed that Resident #25 did not receive the prescribed RNP services. This lack of service delivery was attributed to the RCNA's additional responsibilities, which hindered the consistent provision of restorative therapy to the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who had either an open wound or a urinary catheter, increasing the risk of spreading multidrug-resistant organisms (MDROs). Observations revealed that personal protective equipment (PPE) was not available outside the rooms of residents with urinary catheters, and there were no signs indicating the need for PPE use during direct care. Specifically, residents with indwelling or suprapubic catheters did not have accessible PPE, and staff were observed providing care without using PPE. Additionally, residents with wounds also lacked PPE stations outside their rooms, and staff were observed providing care without PPE. Interviews with the Skin Care team lead nurse and the Director of Nursing/Infection Preventionist indicated a lack of awareness and implementation of updated EBP guidelines. The facility's procedure for EBP required PPE to be accessible and located outside patient rooms, but this was not adhered to, leading to the deficiency.
Lack of Signed Consent Forms for Flu Vaccinations
Penalty
Summary
The facility failed to ensure that a current Influenza Vaccine Informed Consent Form (ICF) was signed by residents prior to receiving the flu vaccine. This deficiency was identified during interviews and record reviews, which revealed that five residents who received the flu vaccine did not have a signed ICF in their medical records. The Director of Nursing confirmed that consents should be part of the medical record, but the Licensed Vocational Nurse (LVN) stated that residents only signed the ICF once, as the form indicated it was an annual requirement. This practice led to the absence of current consent forms for the residents who received the flu vaccine. The record reviews for the five residents showed that they received the flu vaccine on various dates, but their electronic medical records did not contain the necessary ICFs. The LVN mentioned that if a resident refused the vaccination, they would sign a declination form, and a new ICF would be required for future vaccinations. However, this process was not followed for the residents who received the vaccine, resulting in a lack of documentation to confirm whether the vaccine was given or refused, and whether the residents were educated about the vaccine's benefits and risks.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences, specifically regarding access to a call light. The resident, who had decreased mobility due to a history of a stroke, left and right-sided weakness, and impaired balance, required the call light to be within reach at all times. During an observation, the call light was found on a chair behind the resident's bed, out of reach, causing the resident to appear anxious and unable to request assistance for water and a shower. Interviews with a nurse aide and the Director of Nursing confirmed that the call light should have been placed within the resident's reach.
Food Palatability and Preparation Issues
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and met their satisfaction, as evidenced by the experience of one resident. On the evening of 10/27/24, a resident reported that the macaroni salad served during dinner smelled burnt, and the peach cobbler contained salt instead of sugar. Further interviews revealed that on 10/29/24, burnt pasta was found in the refrigerator, indicating issues with food preparation. The Food Service Director acknowledged the problems, attributing them to the new dietary staff who required significant supervision. A grievance form dated 10/28/24 corroborated the resident's complaint, noting that the pasta for the minestrone soup was scorched, coleslaw was served without dressing, and the peach cobbler was improperly prepared.
Latest citations in New Mexico
A clogged floor drain sink in a janitor room led to black, dirty water accumulating in the drain and overflowing into a hallway. A housekeeper reported that the drain, used for disposing of mop water and cleaning chemicals, had been clogged for some time and that she had informed her supervisor. The housekeeping supervisor stated she had submitted several work orders and that housekeeping staff had been attempting to unclog the drain themselves for months, while the maintenance director reported having no active work orders for the issue and indicated that such black water can carry harmful microorganisms. The administrator stated he expects staff to submit work orders and report issues promptly.
Surveyors found that a treatment cart containing drugs and biologicals on two units was left unlocked and unattended, with no staff present. An LPN confirmed the cart belonged to the treatment nurse, who was not on the unit at the time, and acknowledged that it was unlocked. A consultant nurse later stated that treatment carts are required to be locked when not in use.
A resident with impaired cognition had a family member designated as POA with authority over health care and related decisions. The POA, concerned about the resident’s care, repeatedly requested the resident’s medical records but was directed to Medical Records and required to complete written forms, unlike residents who could obtain records via oral request. The POA initially completed the form incorrectly and was told to redo it; the corrected paperwork was not submitted until after the resident’s death, at which point additional documentation was required. Staff, including MR personnel, acknowledged that the POA was authorized to act for the resident and that the resident lacked capacity to request records independently, yet the POA never received the records, resulting in a failure to allow the representative to exercise the resident’s rights.
A resident with impaired cognition and a low BIMS score had a family member designated as POA for health care and related decisions. The POA became concerned about the resident’s care and requested the resident’s medical records but did not receive them. Nursing notes documented the POA’s expressed frustration about still waiting for the records. The Medical Records staff required the POA to complete authorization paperwork twice, stated the first set was completed incorrectly, and reported that corrected paperwork was not returned until after the resident’s death, at which point additional documentation was required. Staff acknowledged that the POA was authorized to act on the resident’s behalf and that, unlike a resident’s own oral request, the POA’s request was not honored without extra paperwork, resulting in the POA never obtaining the records.
A resident’s care plan was not revised to include a family member’s request that a specific housekeeper have no contact with or provide care to the resident in a secure unit, despite the family reporting that this housekeeper had previously caused the resident to fall and had been verbally restricted from working around the resident by prior and current leadership. The housekeeping supervisor and the housekeeper confirmed that the housekeeper no longer worked in the secure unit or with the resident, but the MDS nurse reported she was never informed of this change and therefore did not update the care plan, and the ADON confirmed the care plan lacked this information.
The facility failed to maintain required postings of Ombudsman contact information in accessible areas for residents and their representatives. Surveyor observations found that Ombudsman information was not posted in the facility and that, when present, it was placed on the side of a refrigerator in the Activities Room rather than in a clearly visible location. The Administrator reported that Ombudsman posters had been removed to allow painting and were not re-posted afterward. This deficiency had the potential to affect all residents in the facility, as they and their representatives would not be aware of how to contact the Ombudsman about concerns.
The facility did not maintain the required 18 months of posted nurse staffing records. Surveyors observed that only the current day’s staffing information was posted in the lobby, and during interviews the new DON reported uncertainty about whether historical staffing records were kept. The Administrator later stated that the facility was trying, but unable, to access prior posted staffing information. As a result, residents and the public could not review the required historical nurse staffing data.
The facility did not consistently provide adequate evening and nighttime snacks to residents who requested them. A resident reported that snacks were rarely offered at night and that staff sometimes said none were available. Observation of the nourishment refrigerator showed minimal, often unlabeled items, while CNAs and the Activities Assistant described limited quantities of milk, yogurt, shakes, and sandwiches for multiple residents on each hall. The DM and DON confirmed that snacks were now restricted to those ordered by the RD, with no general snacks left accessible and no staff access to the kitchen at night, resulting in residents without prescribed snacks frequently being told there were not enough snacks and staff occasionally buying snacks themselves.
A resident with a history of cerebral infarction, dementia, and glaucoma did not receive ordered Dorzolamide HCI-Timolol Maleate eye drops after an LPN accidentally discontinued the medication in the system without a physician’s order. The MAR showed the drops were not administered because no active order was available, and nursing documentation later confirmed the facility had discontinued the eye drops without provider authorization. In interviews, the administrator and DON acknowledged that the medication had been stopped in error and that there was no physician order to discontinue it.
A resident with COPD, acute respiratory failure, pulmonary fibrosis, and recent hospitalization for UTI and sepsis returned from the hospital on palliative care with an order for continuous O2 at 2 L/min via nasal cannula. After arrival, staff removed the ambulance’s portable O2 and attempted to use the facility’s O2 concentrators, which were ineffective, while the resident was restless and grabbing at the air. The resident’s daughter reported a period without O2 while staff tried different concentrators and searched for equipment, estimating about 15 minutes before a portable O2 tank was brought back, at which point the NP pronounced the resident deceased. The DON later questioned why a portable O2 tank had not been used when the concentrators failed, and the NP stated the concentrator in use at the time of her assessment was not working properly.
Clogged Janitor Room Floor Drain and Black Water Overflow
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment for all 89 residents when a janitor room floor drain sink on one unit remained clogged and inoperable. During observation of the 400 Unit, water was seen coming from the janitor room into the hallway, and when the door was opened, the floor drain was observed to be filled with approximately 10 inches of black, dirty water. A housekeeper reported that she had spilled water in the hall while dumping her mop bucket into the floor drain sink and had mopped it up, and she confirmed that the drain was clogged and that this sink was used to dispose of cleaning chemicals from mop buckets. The housekeeper stated she had informed her supervisor about the clogged drain, but it had not been fixed and that it had been this way for “a while.” The housekeeping supervisor reported she had made several work orders regarding the janitor room and water overflow and that she and her staff had been unclogging the drain themselves for months. The maintenance director stated that housekeeping is responsible for their department and should notify him if anything is needed, that he had no active work orders regarding water overflow, and that housekeeping should have submitted a work order for the janitor room. He also stated that the black water could carry bacteria, mold, E. coli, salmonella, and possibly Legionella. The administrator stated he expects staff to place work orders and report issues immediately so they can be addressed right away.
Unlocked and Unattended Treatment Cart on Two Units
Penalty
Summary
The deficiency involves the facility’s failure to secure a treatment cart containing drugs and biologicals on the 500 and 600 units, affecting all 27 residents identified on those units by the census list provided by the Administrator on 04/29/26. On 04/29/26 at 8:40 a.m., surveyors observed at the nurses’ station that a treatment cart on the 500/600 unit was left unlocked and unattended, with no staff present. During an interview at 8:44 a.m., an LPN confirmed that the treatment cart was unlocked and identified it as the Treatment Nurse’s cart, noting that the Treatment Nurse was not on the unit at that time. On 04/30/26 at 2:06 p.m., the facility’s consultant nurse stated that treatment carts are supposed to be locked when not in use. The report states that this deficient practice could result in residents obtaining medication not prescribed to them, resulting in adverse side effects. No specific resident medical histories or conditions at the time of the deficiency are described in the report.
Failure to Honor Resident’s POA Request for Medical Records
Penalty
Summary
The facility failed to allow a resident’s designated representative, who held power of attorney (POA), to exercise the resident’s rights by obtaining the resident’s medical records. The resident had impaired cognitive function with a BIMS score of 5 and had formally designated a family member as POA effective 12/24/24, with authority over long‑term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. A nursing progress note documented that the POA approached the ADON and staff, stating she was still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the facility’s process for releasing records created a barrier for the POA, despite staff acknowledging her authority and the resident’s lack of capacity to request records independently. LPN #1 stated that family members requesting medical records had to go to Medical Records (MR). The MR staff confirmed that the POA requested the records and was given paperwork to complete on two occasions; the first form was filled out incorrectly, and the POA was told to redo it. MR reported that the corrected paperwork was not returned until after the resident died, at which point the facility required additional paperwork to release records after death. MR also acknowledged knowing that the POA could act on the resident’s behalf and that, unlike a resident’s oral request, the POA was required to complete written forms. As a result, the POA never obtained the resident’s medical records.
Failure to Provide Resident’s Legal Representative Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with access to the resident’s medical records upon request. The resident had impaired cognitive function, an impaired thought process, and a Brief Interview for Mental Status (BIMS) score of 5, and had designated a family member as Power of Attorney (POA) with authority over long-term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. Nursing progress notes documented that the POA approached the Assistant Director of Nursing and staff, stating they were still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the Medical Records (MR) staff required the POA to complete paperwork to obtain the resident’s medical records, even though MR acknowledged that the POA was legally authorized to act on the resident’s behalf and that the resident did not have the capacity to request records independently. MR reported giving the POA the required forms twice, stating the first set was filled out incorrectly and that the POA needed to complete them again. MR further stated that the POA did not return the corrected paperwork until after the resident’s death, at which point the facility required additional paperwork to release records following a resident’s passing. MR also stated that if a resident personally requested their own medical records, an oral request would be sufficient and no paperwork would be required. Despite the POA’s requests and authority, the POA never received the resident’s medical records. The facility’s policy on determining validity of authorization for release of protected health information required the Medical Records Director to determine whether an authorization was needed for disclosure, but the records were not provided to the POA prior to the resident’s death.
Failure to Update Care Plan With Family’s Restriction on Specific Staff Contact
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect a family member’s request regarding staff contact. Record review showed that the resident’s care plan, last revised on 06/26/25, did not include the family member’s request that a specific housekeeper not have contact with or provide care to the resident in the secure unit. The family member reported that this housekeeper had caused the resident to fall in her room, that the housekeeper was not a CNA in the secure unit, and that the previous Administrator and DON had informed the family member that the housekeeper would no longer work in the secure unit. The family member also stated that this information had been communicated to the current Administrator and DON when they started working at the facility. Interviews with facility staff confirmed that the housekeeper no longer worked in the secure unit and was not to have contact with or provide care to the resident, but this change was not documented in the resident’s care plan. The housekeeping supervisor stated that the housekeeper did not work in the secure unit due to the family member’s wishes. The housekeeper confirmed she no longer worked in the secure unit and was not to be in contact with or care for the resident. The MDS nurse, who is responsible for entering information into residents’ care plans, stated that staff had not informed her of the family member’s request and acknowledged that any changes to a resident’s care should be entered into the care plan. The ADON also confirmed that there was nothing in the care plan reflecting the family member’s wishes and stated that it should have been included.
Failure to Properly Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post the required Ombudsman contact information in areas accessible to residents and their representatives, as required by regulations mandating that names, addresses, and telephone numbers of pertinent State agencies and advocacy groups be posted along with a statement that residents may file a complaint with the State Survey Agency. On 04/29/26 at 9:35 AM, an observation of the facility revealed that staff did not have the Ombudsman information posted. Later that morning at 10:00 AM, an observation of the Activities Room showed that staff had placed an 8.5 x 11-inch paper with Ombudsman information roughly at eye level on the side of a refrigerator, rather than in a more generally visible or designated posting area. On 04/30/26 at 12:47 PM, the Administrator stated in an interview that the facility had taken down the Ombudsman posters in order to paint and confirmed that staff failed to put the Ombudsman posters back up after the painting was completed. This deficiency had the potential to affect all 89 residents identified on the census list provided by the Administrator on 04/29/26, as residents and their representatives would not be aware of how to contact the Ombudsman about concerns they have.
Failure to Maintain 18 Months of Posted Nurse Staffing Records
Penalty
Summary
The facility failed to retain 18 months of records for the daily posted nurse staffing information, affecting all 89 residents as identified on the census list provided by the Administrator on 04/29/26. During an observation of the front lobby at 8:54 AM on 04/29/26, surveyors noted that the current day’s nursing staff information was posted. However, in a subsequent interview at 8:58 AM, the DON, who reported being new to the position, stated she was unsure whether the facility maintained 18 months of the posted nursing staff information. In a later interview on 04/30/26 at 12:47 PM, the Administrator stated that the facility was attempting to obtain access to the historical posted nursing staff information but had been unable to do so. Because the facility did not have 18 months of posted staffing records available, residents or the public would not have access to review the required historical nurse staffing information.
Failure to Provide Adequate Evening and Nighttime Snacks to Residents
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences for evening and nighttime snacks. One resident reported that snacks were not offered very often, especially at night, and that when he asked for a snack he was sometimes told there were none available. Observation of the locked unit nourishment refrigerator showed only one labeled sandwich dated the previous day, along with unlabeled and undated yogurts, sandwich items in a white shopping bag, and two undated and unlabeled metal tumblers. RN staff stated that the snacks in the white shopping bag were intended for all residents who wanted a snack. Multiple CNAs reported that there were not enough snacks at night, noting that the kitchen was locked, and that only a small number of milk cartons, yogurts, supplement shakes, and a few sandwiches were available despite there being about 22 residents per hall. The Dietary Manager stated that snacks were put out three times a day only according to Registered Dietician orders, and that not everyone received a snack; snacks were not left in the refrigerator for residents, and staff could not access the kitchen at night. The DON reported that the kitchen previously put out a lot of snacks but stopped due to waste and cost, and that snacks were now limited to those prescribed by the Registered Dietician. Staff interviews, including CNAs and the Activities Assistant, indicated that residents without prescribed or labeled snacks frequently asked for snacks and were sometimes told there were not enough, leading staff to purchase snacks themselves or use vending machines to meet residents’ requests. These observations and interviews show that residents who wanted or needed snacks, including those with diabetes, did not have consistent access to adequate evening and nighttime snacks.
Unauthorized Discontinuation of Glaucoma Eye Drops
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when an ordered glaucoma eye drop medication for one resident was discontinued without a physician’s authorization. The resident was admitted with diagnoses including cerebral infarction, dementia, and glaucoma. Physician orders showed multiple start dates for Dorzolamide HCI-Timolol Maleate eye drops for both eyes, to be administered in the morning, evening, and at 5:00 a.m., with discontinuation dates entered in the record. Review of the medication administration record for March revealed that the resident did not receive the ordered eye drops because an active order was no longer available. Further review of nursing progress notes documented that the Dorzolamide HCI-Timolol Maleate eye drops had been discontinued by the facility on a specific date without a physician’s order to do so. During interviews, the administrator acknowledged that the eye drops were discontinued by accident and confirmed there was no physician authorization for discontinuation. An LPN reported that she accidentally discontinued the eye drops and did not realize the error for five days, at which point she recognized that the medication had been stopped in error. The DON also stated that the eye drop medication should not have been discontinued by accident because there was no physician order to discontinue it.
Failure to Provide Continuous Oxygen per Physician Orders Due to Equipment Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide continuous oxygen (O2) as ordered for a resident with significant pulmonary conditions. The resident had diagnoses including fracture of the left femur, COPD, acute respiratory failure, and pulmonary fibrosis, and had recently been hospitalized for a UTI and sepsis. Hospital records indicated diagnoses of pulmonary fibrosis, sepsis, and UTI, with a recommendation for palliative care. Upon discharge back to the facility, the physician’s order specified O2 at 2 liters per minute continuously via nasal cannula. Nursing progress notes documented that the resident arrived at the facility on a stretcher wearing 2 liters of O2, was restless and grabbing at the air, and was placed in bed while staff attempted to transition her from the ambulance’s portable O2 to the facility’s O2 concentrator. According to the nursing notes and interviews, the first O2 concentrator was ineffective, and the resident was temporarily placed on a portable O2 tank with a mask. The facility nurse then attempted to use various connectors and obtained another O2 concentrator, which also did not work properly. The resident’s daughter reported that once staff removed the ambulance’s portable O2 and attempted to use the facility concentrator, there was a period during which the resident was not on O2 while staff searched for another concentrator, and that it took approximately 15 minutes for the nurse to return with a portable O2 tank, by which time the nurse practitioner (NP) stated the resident had died and did not need O2. The DON later stated he questioned why a portable O2 tank had not been used when the concentrators were not working to maintain continuous O2 per the physician’s order. The NP confirmed that when she arrived, the resident was on O2 from a facility concentrator that was not working properly and that she did not know how long it had been malfunctioning before the resident’s death.
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