Desert Springs Health Care Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobbs, New Mexico.
- Location
- 1701 N Turner Street, Hobbs, New Mexico 88240
- CMS Provider Number
- 325129
- Inspections on file
- 20
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Desert Springs Health Care Llc during CMS and state inspections, most recent first.
A resident with multiple comorbidities and generalized muscle weakness had a care plan requiring two-person assistance for ADLs, including bathing and bed mobility. During a bed bath provided by one CNA, who reported being unaware of the two-person assist requirement, the CNA remained on one side of the bed while the resident rolled toward the opposite side and fell from the bed to the floor. The resident sustained a laceration to a finger, reported pain in the arm, leg, and hip, and was later found to have a displaced distal femur fracture and a displaced fracture of the fifth finger, requiring surgical repair.
The facility failed to ensure safe and appropriate respiratory care by not maintaining clear and authorized oxygen therapy orders for three residents. One resident with COPD, DM2, and dementia had an order for 2 L O2 to keep SpO2 above 90%, but the order did not specify when O2 should be used, and the resident reported using it only when she felt she needed it. Another resident with CHF, chronic respiratory failure with hypoxia, A-fib, and other cardiac conditions had an order for 2 L O2 with titration to maintain SpO2 at 92%, but the order did not indicate whether O2 was to be continuous or PRN. A third resident with hypertension, kidney failure, DM2, cellulitis, and metabolic encephalopathy was observed on O2 via nasal cannula and concentrator without any physician order in place for supplemental O2 use, as confirmed by the DON.
Surveyors found that two residents were receiving medications without appropriate indications based on their documented diagnoses. One resident, whose conditions included heart disease, Alzheimer’s disease, DM2, and CKD, had an order for apixaban twice daily for A-fib despite having no A-fib diagnosis. Another resident, diagnosed with DM2, bipolar disorder, HTN, COPD, and RA, was ordered memantine and Aricept at bedtime for Alzheimer’s disease, although this diagnosis was not present in the record. The DON confirmed in interviews that these residents did not have the diagnoses for which the medications were ordered and stated that medications should only be ordered and administered for conditions the residents actually have.
Surveyors found that the facility did not consistently implement its infection prevention and control program when two residents who required contact or Enhanced Barrier Precautions did not have appropriate precaution signage posted or PPE readily available outside their rooms. One resident with active shingles and an order for contact precautions had no contact precaution sign or accessible PPE at the room entrance. Another resident with multiple pressure injuries and other wounds, with several wound care orders in place, lacked an EBP sign on the room door, a fact later confirmed by a CNA.
A resident with a history of traumatic SDH, anemia, urinary retention, and repeated falls, and a BIMS score indicating moderate cognitive impairment, was on a dietician-ordered regular diet with soft and bite-sized texture and thin liquids. During a meal, the resident requested a tortilla but was denied based on the diet order and subsequently refused to eat the meal. In a later interview, the resident stated understanding the choking risk yet still wished to have a tortilla. The DON confirmed the resident’s right to refuse dietary orders and that staff should have involved nursing or the dietician to allow the resident to exercise this choice, but this did not occur.
Surveyors found that the facility did not ensure that two residents' advance directives and New Mexico MOST forms matched the code status orders in the EHR. For one resident, the EHR listed Full Code while the signed advance directive and MOST form indicated DNR, which the DON confirmed was inaccurate. For another resident, the medical orders reflected DNR status while the MOST form documented a preference for Full Code with CPR. The DON acknowledged that these discrepancies did not meet expectations and that the orders should match the residents' MOST forms.
A resident with active physician orders for Zoloft for depression, Depakote and Gabapentin for dementia with behaviors and anxiety, and Aspirin and Clopidogrel for stroke prophylaxis was inaccurately coded on the MDS. In Section N – Medications, staff documented that the resident was not receiving antidepressant, anticonvulsant, or antiplatelet medications, and the MDS coordinator later confirmed that this assessment was incorrect.
A resident was admitted without a baseline care plan being developed and implemented within 48 hours, as required. Review of the EHR showed no baseline care plan, and the comprehensive care plan was not initiated until a later date. In an interview, the DON confirmed that a baseline care plan had not been completed for this resident, despite the expectation that all new admissions have such a plan in place within 48 hours.
A resident was receiving supplemental O2 via nasal cannula and had a floor mat placed beside the bed, but the facility failed to develop and implement a comprehensive care plan addressing these interventions. Record review showed an active O2 order without corresponding care plan interventions, and there was no order for the floor mat. Observations confirmed the resident’s use of O2 and the floor mat, and both the ADON and DON acknowledged that these should have been included in the care plan but were not.
A resident with COPD, DM2, and dementia had a physician order for oxygen at 2 L via nasal cannula to maintain oxygen saturation above 90%. The care plan documented continuous oxygen use at 2 L, but observations showed the resident was not on oxygen and reported using it only when needed. The DON confirmed the resident used oxygen on an as-needed basis and that the care plan had not been revised to reflect this current oxygen intervention, resulting in an inaccurate care plan.
A resident with multiple chronic conditions, including CKD, dementia, Alzheimer’s disease, muscle weakness, and a history of falls, was found during wound care to have an overgrown great toenail curving toward the adjacent toe. An LPN reported that podiatry provides quarterly nail care and that CNAs, nurses, or providers are expected to trim nails between podiatry visits, with the resident’s next podiatry appointment not yet due. The DON stated that staff are responsible for ensuring nails do not become overgrown and acknowledged that the resident’s toenail condition did not meet her expectations.
A resident with DM2, depression, anxiety, and dementia was receiving Risperidone, but the consent form on file listed schizophrenia as the indication while the current MD order listed dementia without behavioral disturbance. A pharmacist’s review noted that consent for Risperidone related to dementia with behavior disturbance could not be found and requested an update to the record. The MDS regional coordinator later confirmed that the consent did not match the current physician order, demonstrating the facility’s failure to maintain an accurate and updated medical record for this medication.
The facility failed to assess the risk of entrapment for residents using bed rails, affecting five residents. Although risks and benefits were reviewed, necessary bedrail assessments were not completed, and alternatives to bed rails were not considered. The DON acknowledged the oversight, stating that consent forms were completed but was unaware of the need for separate assessments.
The facility did not post daily nurse staffing data as required. Observations on November 16, 2024, revealed no current staffing information at the main nurses' station, and outdated information in the 100 hall, last updated on September 26, 2024. Interviews with an LVN and an RN confirmed the absence and outdated status of the postings.
A resident at risk for falls fell during a bed bath due to improperly locked bed wheels. The staff member was unfamiliar with the bed equipment, leading to the bed moving and the resident falling, resulting in injuries requiring hospital treatment.
Failure to Follow Two-Person Assist Care Plan During Bed Bath Resulting in Fall and Fractures
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during personal care, resulting in a fall with injury. The resident was admitted with multiple diagnoses including chronic systolic heart failure, major depressive disorder, morbid obesity, type 2 diabetes mellitus, and generalized muscle weakness. Her care plan, revised on 06/03/25, specified that she required two-person assistance for bathing/showering, bed mobility, dressing, toilet use, and transfers with a Hoyer lift. On 12/27/25, progress notes documented that the resident was in her room with her husband and requested a bed bath. During this bed bath, she fell from her bed, sustained a laceration to her left pinky finger, and complained of pain to her left arm, leg, and hip. Interview with CNA #2 revealed that he responded to the resident’s request for a bed bath and provided care while positioned on one side of the bed. During the bath, the resident rolled toward the opposite side of the bed, and CNA #2 was unable to prevent her from rolling out of the bed, resulting in her fall to the floor. CNA #2 stated he assisted the resident without a second staff member because he was unaware that she required two-person assistance as outlined in her care plan. The DON stated that residents who require two-person assistance are expected to receive help from two staff members and that CNA #2 should have been informed of this requirement during shift report. Hospital records later documented that the resident was admitted with a displaced oblique fracture of the distal femur and a displaced fracture of the middle phalanx of the fifth finger and underwent surgery to repair these fractures.
Failure to Maintain Clear and Authorized Oxygen Therapy Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not having clear or complete oxygen orders for multiple residents. One resident with COPD, DM2, and dementia had a physician order for oxygen at 2 L via nasal cannula to keep oxygen saturation above 90%, but the order did not specify when the oxygen should be used. During observation, this resident was not wearing oxygen and the concentrator was off; the resident stated she only wears oxygen when she needs it. The DON confirmed that the resident only wears oxygen as needed and that the order did not specify when oxygen should be worn, acknowledging that it should. Another resident with CHF, chronic respiratory failure with hypoxia, major depressive disorder, A-fib, sleep apnea, and atherosclerotic heart disease had an order for 2 L of oxygen via nasal cannula with titration to maintain oxygen saturation at 92%, but the order did not indicate whether oxygen was to be administered continuously or PRN. The DON confirmed this lack of specificity and stated the order should indicate when to administer oxygen. A third resident with hypertension, kidney failure, DM2, cellulitis of the right lower limb, and metabolic encephalopathy was observed lying in bed wearing a nasal cannula connected to an oxygen concentrator. The ADON confirmed the resident was on oxygen, and the DON later confirmed that this resident did not have a medical order for oxygen use, despite using supplemental oxygen.
Medications Administered Without Corresponding Diagnoses
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary medications by not confirming that ordered drugs had appropriate indications based on current diagnoses. For one resident, admitted with diagnoses including atherosclerotic heart disease, Alzheimer’s disease, atherosclerosis of coronary artery bypass grafts, type 2 diabetes mellitus, and chronic kidney disease, the medical record contained an order for apixaban 2.5 mg orally twice daily for atrial fibrillation. Record review and interview with the DON confirmed that this resident did not have a diagnosis of atrial fibrillation, and the DON acknowledged that this did not meet her expectations because medications should be ordered and administered only for diagnoses the resident has. For another resident, admitted with diagnoses including type 2 diabetes mellitus, bipolar disorder, essential hypertension, COPD, and rheumatoid arthritis, the current medical orders included memantine 10 mg (two tablets at bedtime) and Aricept 10 mg (one tablet at bedtime), both ordered for Alzheimer’s disease. Record review and the DON’s interview confirmed that this resident did not have a diagnosis of Alzheimer’s disease, despite receiving two medications specifically ordered for that condition. The DON stated that medications should only be ordered and administered for diagnoses the resident has, confirming that these orders did not align with the resident’s documented conditions.
Failure to Post Precaution Signage and Provide PPE for Residents Requiring Enhanced Barrier and Contact Precautions
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program by not ensuring that required Enhanced Barrier Precautions (EBP) and contact precautions were visibly posted and supported with readily available PPE for certain residents. One resident with focal traumatic brain injury, zoster (shingles), and an elevated white blood cell count had a physician order dated 01/13/26 for contact precautions due to an active shingles infection described as highly transmissible and acquired by physical contact. On 01/28/26 at 1:49 pm, observation of this resident’s room showed there was no sign on the door indicating contact precautions and no PPE readily accessible outside the room, despite the active order. Another resident with multiple diagnoses including hypertension, kidney failure, type 2 diabetes mellitus, cellulitis of the right lower limb, and metabolic encephalopathy had multiple wound care orders dated 01/23/26 for unstageable pressure injuries and other wounds to the left hip, right and left ischium, both heels, sacrum, and right big toe. During a random observation of this resident’s room on 01/28/25 at 1:29 pm, there was no EBP sign posted. In a subsequent interview on 01/30/26 at 11:28 am, a CNA confirmed that this resident did not have an EBP sign posted, demonstrating that the facility did not consistently implement its infection prevention and control measures for residents requiring enhanced precautions.
Failure to Honor Resident Choice Regarding Dietary Orders
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices about significant aspects of their life, specifically the right to refuse dietician orders. The resident was admitted with diagnoses including traumatic subdural hemorrhage, anemia, urinary retention, and repeated falls. A quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Dietician orders dated 01/09/26 specified a regular diet with soft and bite-sized texture and thin liquid consistency. During a dining room observation on 01/28/26 at 12:52 pm, the resident requested a tortilla and was told he could not have one due to his diet order, after which he pushed his plate away and did not eat his meal. Later that afternoon, during an interview, the resident stated he really wanted to eat a tortilla, reported he had been told he could not have one because he might choke, and stated he understood the risks and still wanted a tortilla. In a subsequent interview on 01/30/26 at 4:26 pm, the DON confirmed the resident was on a soft, bite-sized diet and acknowledged that the resident had the right to refuse his dietary orders. The DON stated that staff should have communicated with the nurse or dietician to provide the resident the opportunity to refuse his dietary orders so he could have a tortilla, confirming that this process did not occur at the time of the incident.
Mismatch Between Advance Directives, MOST Forms, and EHR Code Status Orders
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' current advance directives and New Mexico Orders for Scope of Treatment (MOST) forms matched the code status orders in the electronic health record (EHR) for two residents. For one resident, the face sheet showed admission on a specified date, and the physician orders in the EHR documented the resident as Full Code for advance directive code status. However, the resident's current advance directive and MOST form, signed on a later date, indicated the resident had chosen Do Not Resuscitate (DNR). During an interview, the DON confirmed that this resident's code status should be DNR and not Full Code, acknowledging the inaccuracy and that staff had not updated the resident's code status in the EHR. For another resident, the admission record showed admission on a specified date, and the current medical orders included an order, dated on a specific day, to not attempt resuscitation due to DNR status. In contrast, the resident's MOST form, dated on another specific day, documented that the resident chose to be Full Code and wanted CPR performed if needed. In an interview, the DON stated that this discrepancy did not meet her expectations because the resident's medical order should match the MOST form, but it did not. The report states that this deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred.
Inaccurate MDS Medication Coding for Psychotropic and Antiplatelet Drugs
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when required medication use was not correctly documented. Record review showed that this resident had multiple active physician orders, including Zoloft 100 mg daily for depression, Depakote Sprinkles 125 mg two capsules twice daily for dementia with behaviors, Gabapentin 300 mg twice daily for anxiety, Aspirin 81 mg daily for prophylactic measures related to a history of stroke, and Clopidogrel 75 mg daily for prophylactic measures related to a history of stroke. These orders established that the resident was receiving antidepressant, anticonvulsant, and antiplatelet medications during the assessment period. Despite these active medication orders, the resident’s MDS, in Section N – Medications, indicated that the resident did not take antidepressant, anticonvulsant, or antiplatelet medications. During an interview, the MDS coordinator confirmed that the assessment for this resident was inaccurate and acknowledged that it should have reflected the use of antidepressant, anticonvulsant, and antiplatelet medications but did not.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review showed that this resident was admitted on an identified date, but there was no evidence of a baseline care plan in the Electronic Health Record. Further review revealed that the resident’s comprehensive care plan was not developed and implemented until a later date, well beyond the required 48-hour timeframe for a baseline care plan. During an interview, the DON confirmed that the facility did not develop and implement a baseline care plan for this resident and stated that her expectation is that every resident has a baseline care plan in place within 48 hours of admission. The report notes that if the facility fails to develop and implement a baseline care plan, residents might not receive the care and services they need.
Failure to Care Plan for Oxygen Use and Floor Mat
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive care plan for a resident when staff did not include interventions for the use of supplemental oxygen and a floor mat. The resident was admitted on an identified date, and review of the care plan dated shortly after admission showed no care plan addressing the resident’s use of supplemental oxygen or the presence of a floor mat. Medical orders showed that the resident had an order, dated several days after admission, for supplemental oxygen via nasal cannula, but there was no corresponding care plan with interventions for this treatment. Surveyor observations and staff interviews confirmed the omission. During a random observation of the resident’s room, the resident was seen lying in bed wearing a nasal cannula connected to an oxygen concentrator, and a floor mat was present on the floor next to the right side of the bed. The ADON confirmed that the resident was using oxygen and had a floor mat in place. The DON also confirmed the resident’s use of oxygen and a floor mat and acknowledged that both should have been included in a care plan with interventions prior to their use, but were not.
Failure to Revise Care Plan to Reflect PRN Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to revise and maintain an accurate care plan regarding a resident’s oxygen use. The resident was admitted with COPD, type 2 diabetes mellitus, and dementia. A physician’s order dated 08/14/25 directed oxygen via nasal cannula at 2 L to maintain oxygen saturation above 90%. The resident’s care plan, revised on 12/31/25, documented that the resident used oxygen via nasal cannula at 2 L continuously. However, this care plan was not updated to reflect the resident’s actual pattern of oxygen use. During an observation on 01/28/26, the resident was seen in her room with an oxygen concentrator next to the bed, but she was not wearing the nasal cannula and the machine was turned off. The resident stated she only wears her oxygen when she needs it. In a subsequent interview on 01/30/26, the DON confirmed that the resident only uses oxygen as needed and acknowledged that the care plan was not accurate and should have been revised. This failure to revise the care plan to reflect current oxygen interventions constituted the cited deficiency.
Failure to Maintain Appropriate Toenail Care Between Podiatry Visits
Penalty
Summary
The facility failed to provide adequate foot care for one resident when staff allowed a toenail to become overgrown between podiatry visits. The resident, who had multiple diagnoses including metabolic encephalopathy, chronic kidney disease, generalized muscle weakness, dementia, Alzheimer’s disease, and a history of repeated falls, was observed during wound care to the right ankle, at which time an LPN removed the resident’s sock and revealed an overgrown right great toenail that was curving slightly toward the second toe. Record review showed the resident had been admitted with these conditions, and interview with the LPN confirmed that quarterly podiatry appointments are made for nail care and that CNAs, nurses, or providers are expected to trim nails between podiatry visits; the LPN also confirmed the resident’s next podiatry appointment was scheduled for a later date. In a separate interview, the DON stated that CNAs, nurses, or providers should ensure nails do not become overgrown and acknowledged that the condition of this resident’s toenail did not meet her expectations.
Inaccurate Antipsychotic Consent Documentation
Penalty
Summary
The facility failed to maintain an accurate and updated medical record for one resident when the documented consent for an antipsychotic medication did not match the current physician order. The resident was admitted with diagnoses including Type 2 DM, major depressive disorder, anxiety, and dementia. A pharmacist’s Medication Regimen Review dated 11/26/25 noted that a consent could not be found for the resident’s Risperidone for the diagnosis of dementia with behavior disturbance and requested that the record be updated once consent was obtained. Review of the current consent for Risperidone, dated 08/26/24, showed it was completed for the diagnosis of schizophrenia. Further record review showed that the physician’s order dated 10/20/25 listed the indication for Risperidone as dementia, unspecified severity, without other behavioral disturbance, which did not match the diagnosis documented on the existing consent form. During an interview on 01/30/25, the MDS regional coordinator confirmed that the consent did not match the physician’s orders and acknowledged that the consent should be updated to reflect the current order. This discrepancy demonstrated that the facility did not ensure the resident’s medical record, specifically the consent for Risperidone, was accurate and consistent with the physician’s current orders.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that staff assessed residents who utilized bed rails for the risk of entrapment. This deficiency affected five residents who used bed rails, as staff did not complete the necessary bedrail assessments. Although the risks and benefits of bed rails were reviewed with the residents, the assessments to evaluate the risk of entrapment were not conducted. Additionally, staff did not attempt to use appropriate alternatives to bed rails or determine if these alternatives met the residents' needs, as no bedrail assessments were completed. During an interview, the Director of Nursing (DON) acknowledged that staff did not complete bedrail assessments. The DON mentioned that consent forms for the use of bedrails were completed, but she was unaware that a separate bedrail assessment was required. This oversight could potentially lead to residents experiencing injury by becoming trapped between the mattress and the bedrail.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing data, which is a requirement. On November 16, 2024, at 1:15 pm, it was observed that there was no nurse staffing information posted for the day at the main nurses' station. Additionally, the staffing information available at the nurses' station in the 100 hall was outdated, with the last update being on September 26, 2024. During an interview, an LVN confirmed that the nurse staffing information was not posted as required at the main hall nurses' station. Furthermore, an RN corroborated that the staffing information in the 100 hall was outdated, confirming the date discrepancy.
Failure to Lock Bed Wheels Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was at risk for falls due to weakness and a history of falls. The incident occurred when the resident was receiving a bed bath, and the bed was not fully locked. Specifically, the wheels at the top of the bed were not locked, which allowed the bed to move when the resident braced herself against the wall. This movement caused the resident to fall to the ground, resulting in injuries that required hospital treatment. The staff member providing the bed bath was not familiar with the proper use of the bed and its brakes, contributing to the incident. The resident required maximal assistance for movements such as rolling and sitting up, indicating a high level of dependency on staff for safe transfers. The failure to ensure the bed was fully locked and the staff's unfamiliarity with the equipment were key factors leading to the resident's fall and subsequent injuries.
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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