Gallup Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Gallup, New Mexico.
- Location
- 306 East Nizhoni Blvd, Gallup, New Mexico 87301
- CMS Provider Number
- 325118
- Inspections on file
- 23
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Gallup Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow physician-ordered parameters for blood pressure (BP) medications for two residents. For one resident, lisinopril was given despite a systolic BP below the ordered hold parameter. For another resident, carvedilol was withheld on two occasions even though the documented BP and heart rate were within the ordered range for administration, and required nursing notes explaining the omissions were not entered. The DON confirmed that vital signs should be documented in the MAR and that medications must be administered or held according to provider orders, which did not occur in these cases.
Surveyors found that a resident room had multiple strips of floor tape that were worn, curling, and leaving sticky, uneven residue near the bedside area, and that a hallway near the dining room had a hose connected to a wall-mounted water source by an ice machine that was not properly secured in its protective case, causing water to drip and form a puddle on the floor. The Maintenance Supervisor and the ADM acknowledged that floor tape should remain flat and that the hose should be secured to prevent tripping and slipping hazards for residents.
Surveyors found that multiple resident rooms and bathrooms were not maintained in safe and functional condition, including windowsills separating from walls with visible gaps, loose tiles near beds, damaged heating vents, and an electrical outlet housing separated from the wall. Walls and bathroom doors in several rooms had scuff marks, chipped or uneven paint, and visible unpainted wood putty. According to the Maintenance Supervisor, surfaces should be evenly painted, windowsills should not separate from walls, and rooms are expected to be kept in good repair so that residents feel at home.
A resident was admitted and did not have a baseline care plan developed within 48 hours as required by facility policy. Record review showed the baseline care plan was initiated more than two days after admission. In interviews, the DON and the Administrator confirmed their expectation that baseline care plans be completed within 48 hours, and acknowledged that this did not occur for this resident.
A resident with HTN and cardiac conditions had a physician order for carvedilol to be held only if SBP was below a specified threshold or HR was under 60 bpm. On two occasions, the MAR showed carvedilol doses as not administered with instructions to see a nurse or progress note, even though the recorded vital signs were within ordered parameters for administration. No corresponding nursing or progress notes were found to explain why the doses were held, while other doses with similar vital signs were documented as given. The DON confirmed that when a medication is marked as held with a direction to see a note, a note explaining the reason is expected, and acknowledged the medical record was not accurate.
A resident with dementia, bladder neck obstruction, and an indwelling Foley catheter for chronic urinary retention was observed on multiple occasions without required catheter privacy measures and with improper tubing positioning. The facility’s policy required drainage bags to be covered with a privacy bag when out of bed and catheter tubing to be secured off the floor. During meal and common-area observations, the resident’s drainage bag lacked a privacy cover and the catheter tubing was seen touching the floor. CNAs, the DON, and the Administrator all acknowledged that catheter bags should be covered and tubing should not drag on the floor, confirming that established infection control procedures were not followed.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall resulting in a head injury. Despite facility policy, no neurological checks were documented, leading to a delay in identifying a severe brain bleed. The resident's condition worsened, resulting in hospitalization and eventual passing.
A resident experienced an unwitnessed fall resulting in a head injury, which was not reported to the SSA as required by the facility's policy. The resident was found on the floor with a cut over the right eye and later sent to the ER for a CT scan due to altered mental status. The incident was not logged in the facility's Incident Report Log, and the administrator was unaware of the event, as the responsible agency nurse was no longer employed.
The facility's binding arbitration agreement failed to include a provision for selecting a convenient venue for arbitration proceedings. This deficiency was confirmed by the facility Administrator and noted during a record review. Although the facility's Admission Guide mentioned the provision, it lacked a signed acknowledgment from residents, potentially affecting 56 of the 57 residents who signed the agreement.
A resident felt disrespected when a staff member closed his room door without proper communication, as his music was deemed too loud during a nearby meeting. The Housekeeping Manager informed the roommate instead of the resident and did not wait for a response, assuming agitation. This action violated the resident's rights to dignity and respect.
A facility failed to create a Baseline Care Plan within 48 hours for a newly admitted resident with complex medical conditions, including acute respiratory failure and post-COVID-19 condition. The plan was completed three days post-admission, as confirmed by the Administrator, which deviated from required protocols.
A resident with hepatic encephalopathy did not receive a prescribed dose of lactulose due to staff holding the medication after the resident experienced loose stools. The DON clarified that the medication was intended to manage encephalopathy, not constipation, and loose stools were a sign of the medication's effectiveness.
Failure to Follow BP Medication Parameters and Document Withheld Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not following physician orders for blood pressure medications for two residents. For one resident, a physician’s order dated 07/16/25 directed that lisinopril be held if the systolic blood pressure was less than 110 mmHg. Review of the Medication Administration Record (MAR) from 01/01/26 to 01/21/26 showed that on 01/05/26, staff administered lisinopril despite a documented systolic blood pressure of 105 mmHg, which was below the ordered hold parameter. For the second resident, a physician’s order dated 11/20/25 specified that carvedilol for hypertension be held only if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute. The MAR for 01/01/26 to 01/21/26 showed that on 01/01/26, a dose of carvedilol was not administered and was marked “see progress note,” even though the recorded systolic blood pressure was 118 mmHg and heart rate was 70 beats per minute, both within parameters; the corresponding progress notes from 01/01/26 to 01/02/26 contained no documentation explaining the withheld dose. On 01/16/26, the evening dose of carvedilol was again not administered and referenced a nurse’s note, while the MAR documented a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the ordered parameters, and nursing notes from 01/16/26 to 01/17/26 did not document a reason for withholding the medication. During an interview, the DON confirmed that vital signs are expected to be documented in the electronic MAR and that medications should be administered or held according to the provider’s parameters, and acknowledged that staff did not follow the orders in these instances.
Failure to Maintain Safe Flooring and Control Water Leakage Hazards
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe environment when multiple strips of adhesive tape were observed on the bedroom floor near the bedside area in Room 41. Several of these tape strips were worn, partially detached, and curling upward at the edges, and dark adhesive residue remained where tape had deteriorated or been removed, creating uneven and sticky surface areas. These conditions were directly observed in the resident room and were acknowledged by the Maintenance Supervisor, who stated his expectation that tape applied to floors should be flat to the ground to prevent a tripping hazard. Surveyors also observed a deficiency in the hallway leading to the dining room, where a hose connected to a wall-mounted water source next to the ice machine was actively dripping water onto the floor, forming a small puddle. The hose was supposed to be secured within a clear plastic protective case, but the case did not securely hold the hose in place, allowing the dripping to occur in an area accessible to all residents. In interviews, both the Maintenance Supervisor and the Administrator stated that the hose nozzle should be secured inside the clear plastic case to prevent water from dripping onto the floor and that tape placed on the floor should remain flat with the surface to prevent residents from tripping or falling.
Failure to Maintain Safe and Functional Resident Room Environments
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, and functional physical environment in multiple resident rooms and bathrooms. Observations showed that several windowsills were separating from the wall, unpainted, or had loose tiles, including in rooms near specific beds where gaps of approximately 0.5 to 1 inch were noted between the sill and the wall. In one room, the windowsill closest to a bed was unpainted and separating from the wall, while in other rooms the windowsills near beds had loose tiles or were separating from the wall. An electrical outlet housing behind a bed was also observed to be separated from the wall. Additional observations revealed scuff marks, chipped paint, and uneven paint coverage on bathroom walls and other wall surfaces in several rooms. One room’s interior bathroom door had visible, unpainted wood putty, and the bathroom door and multiple walls had uneven paint coverage, with scuffed walls behind a bed. Another room’s heating vent had three broken horizontal slats, indicating the vent was damaged and could not properly control the flow of warm air, and the same room’s bathroom walls had scuff marks and chipped paint. During an interview, the Maintenance Supervisor stated that scuff marks should be painted evenly, windowsills should be in good repair and not separating from the wall, and that it was his expectation that resident rooms be in good repair so residents feel like they are at home.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident. The facility’s policy on Care Plans – Baseline, dated December 2016, required that a baseline care plan be developed within 48 hours of a resident’s admission to ensure the resident’s immediate care needs are met and maintained. Record review showed that the resident was admitted on an identified date, but the baseline care plan for this resident was not initiated until 01/12/26, which was more than 48 hours after admission. During interviews, the DON stated that it was her expectation that the resident’s baseline care plan should have been completed on 01/11/26, and the Administrator stated that it was her expectation that residents’ baseline care plans be completed within 48 hours of admission. This deficiency was identified for 1 of 1 resident reviewed for baseline care plans and was based on record review of the resident’s face sheet and baseline care plan, as well as staff interviews confirming that the facility did not meet its own policy requirement for timely completion of the baseline care plan.
Incomplete Documentation of Held Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to medication administration for one resident prescribed carvedilol for hypertension and other cardiac conditions. The physician’s order dated 11/20/25 directed that carvedilol be held only if the resident’s systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute. Review of the Medication Administration Record (MAR) for 01/01/26 showed the morning dose of carvedilol was documented as not administered with a direction to “see progress note,” while the recorded vital signs that morning were a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which were within the ordered parameters for administration. No corresponding progress note was found for that date explaining why the medication was withheld. Further review of the MAR from 01/01/26 to 01/21/26 showed that the evening dose of carvedilol on 01/01/26 was documented as administered, with the same vital signs recorded for that evening as in the morning (systolic blood pressure 118 mmHg and heart rate 70 beats per minute). On 01/16/26, the evening dose of carvedilol was again documented on the MAR as not administered with a notation to “see nurses note,” yet the resident’s vital signs that day showed a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the parameters for giving the medication. No nursing note was entered on 01/16/26 or 01/17/26 to explain the reason for withholding the dose. In an interview, the DON stated that when a nurse documents a medication as held with a direction to see a note, it is expected that a corresponding note be entered, and confirmed that the resident’s medical record regarding medication administration was not accurate.
Failure to Maintain Catheter Privacy and Tubing Position per Infection Control Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care and infection prevention procedures for a resident with an indwelling Foley catheter. The facility’s Catheter Care Procedure, last revised June 2020, required that catheter drainage bags be kept below the level of the bladder, off the floor, and covered with a privacy bag when the resident is out of bed. The resident, originally admitted with dementia and bladder neck obstruction and assessed with a BIMS score indicating severe cognitive impairment, had physician orders for an indwelling Foley catheter PRN for chronic urinary retention. During a lunch observation in the dining room, the resident was seen sitting in a wheelchair with the catheter drainage bag uncovered, without the required privacy bag. In a separate observation in a common TV area, the same resident was seen in a wheelchair with the urinary catheter tubing touching the floor, contrary to the facility’s policy to keep tubing off the floor. Staff interviews confirmed that these practices did not meet facility expectations: a CNA stated that all residents should have a privacy bag covering their urinary drainage bags, another CNA reported that the previous CNA had forgotten to attach the catheter bag to the chair and acknowledged that the tubing should not be dragged on the floor, and both the DON and the Administrator confirmed that catheter tubing should not touch the ground and that a privacy bag should always be in place when residents are out of their rooms. These observations and statements demonstrate that the facility did not maintain its infection prevention and control program for this resident’s catheter care.
Failure to Conduct Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall that resulted in injury. The resident, who had a history of frequent falls and was at high risk for falls due to multiple medical conditions including Parkinson's Disease, dementia, and generalized muscle weakness, was found on the floor with a laceration over his right eye. Despite the facility's policy requiring neurological checks for 72 hours following an unwitnessed fall, no neuro evaluations were completed or documented for the resident. The resident's condition deteriorated over the following days, with vital signs indicating changes and a noted alteration in mental status. The resident was eventually sent to the emergency room for a CT scan, which revealed a large left temporal lobe bleed and other significant brain hemorrhages. The lack of timely and appropriate neurological assessments likely contributed to the delay in identifying the resident's life-threatening condition. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the expected neurological checks were not performed. The facility's failure to adhere to its own post-fall assessment and monitoring policy resulted in the resident's hospitalization and subsequent passing, highlighting a significant deficiency in the care provided to the resident.
Failure to Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury for a resident to the State Survey Agency (SSA), as required by their policy. The incident involved a resident who was found on the floor in their room with a cut over the right eye. The nursing progress notes indicated that the resident was later sent to the emergency room for a CT scan due to a change in mental status. Despite these events, the facility's Incident Report Log did not contain any record of the fall being reported. The facility's policy mandates that a licensed nurse complete an incident report and perform a post-fall assessment following each resident fall. Additionally, a Neurological Flow Sheet should be completed for any unwitnessed fall or witnessed fall with a head injury. However, the administrator confirmed that the incident was not reported to her, and thus, not filed with the SSA. The nurse responsible for documenting the fall was an agency nurse who is no longer employed at the facility, which contributed to the failure in reporting the incident.
Arbitration Agreement Lacks Venue Provision
Penalty
Summary
The facility failed to ensure that their binding arbitration agreement included a provision for the selection of a convenient venue, which is necessary for arbitration proceedings. This omission could potentially deter residents from exercising their rights to seek arbitration due to the inconvenience and frustration it may cause. The deficiency was identified during a record review of the facility's Voluntary Arbitration Agreement, which was found to be undated and lacking the necessary provision. During an interview, the facility Administrator confirmed the absence of this provision in the arbitration agreement, although it was mentioned in the facility's Admission Guide. However, the Admission Guide did not include a signed acknowledgment from residents confirming receipt, understanding, and inclusion of this provision as part of the Voluntary Arbitration Agreement. This issue has the potential to affect 56 of the 57 facility residents who signed the binding arbitration agreement.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
The facility failed to uphold a resident's rights to dignity and respect when a staff member closed a resident's room door against his wishes and without proper communication. The incident involved a resident who was listening to music at a volume audible in the hallway. The Housekeeping Manager (HM) closed the door at the request of the facility Administrator due to a nearby staff meeting. The HM informed the resident's roommate instead of the resident himself and did not wait for the resident's response, assuming he was agitated. This action led the resident to feel disrespected and uncared for by the staff.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a Baseline Care Plan within 48 hours of admission for one of the residents reviewed. This deficiency was identified during a record review and interview process. The resident in question, identified as R #108, was admitted with multiple complex medical conditions, including acute respiratory failure with hypoxia, type 2 diabetes mellitus with neuropathy, hyperlipidemia, obstructive sleep apnea, hypertension, atherosclerotic heart disease, congestive heart failure, pneumonia due to coronavirus disease, asthma, muscle wasting and atrophy, overactive bladder, difficulty in walking, and post-COVID-19 condition. Despite these significant health issues, the baseline care plan, which is crucial for ensuring immediate and appropriate care, was not created until more than 48 hours after the resident's admission. The delay in creating the baseline care plan was confirmed during an interview with the facility's Administrator, who acknowledged that the staff did not complete the plan within the required timeframe. The baseline care plan for the resident was only completed three days after admission, which is a clear deviation from the expected protocol. This oversight could potentially lead to a decline in the resident's condition due to the staff's lack of awareness of the necessary care requirements, as the baseline care plan is essential for guiding immediate care upon admission.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to meet professional standards of practice in the administration of medication for a resident diagnosed with hepatic encephalopathy. The resident was prescribed lactulose, a medication intended to decrease ammonia levels in the blood, to be administered 45 milliliters by mouth three times a day. However, a review of the Medication Administration Record for September 2024 revealed that the midday dose of lactulose was not administered on September 3, 2024, due to a note to hold the medication. The nurse's progress note indicated that the resident had experienced three loose stools since the morning, which led to the decision to withhold the medication. During an interview, the Director of Nursing stated that the lactulose should not have been held due to loose stools, as the medication was prescribed to manage encephalopathy, not constipation, and loose stools were indicative of the medication's desired effect.
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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