Grants Wellness & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Grants, New Mexico.
- Location
- 840 Lobo Canyon Road, Grants, New Mexico 87020
- CMS Provider Number
- 325058
- Inspections on file
- 17
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Grants Wellness & Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that multiple residents were kept in cold rooms on one unit where thermostats in individual rooms did not function and temperatures were controlled from the nurse’s station, with staff acknowledging frequent complaints about the cold and the lack of temperature logs. In addition, a resident with atopic dermatitis, type 2 DM with neuropathy, varicose veins with inflammation, and dementia was observed multiple times lying directly on a bare plastic mattress without sheets or blankets, despite CNA, RN, and DON expectations that beds be remade immediately after linens are removed and that residents not remain on uncovered mattresses.
A resident with diabetes, prior TIA and stroke, cognitive communication deficit, and depression had multiple MDS assessments in which Section C (Cognitive Patterns) was repeatedly left incomplete. Across several assessments, items determining whether BIMS should be conducted, the BIMS questions themselves, the staff assessment for mental status, and short- and long-term memory fields were left unanswered or dashed, resulting in no BIMS score while some cognitive items were still coded (e.g., memory and decision-making). The MDS Coordinator confirmed responsibility for these assessments and acknowledged that Section C was expected to be fully completed but was not.
A resident with Type 2 DM, neuropathy, paraplegia, and reduced mobility had a physician order for daily diabetic foot checks, including skin assessment, shoe inspection, and pedal pulse checks, but this care was not documented as completed over an extended period. The resident’s care plan did not include diabetic foot care despite the order. A later podiatry consult identified thickened, painful toenails, nail dystrophy, localized edema, and slightly diminished foot and ankle ROM, and the podiatrist performed nail debridement and recommended ongoing daily foot checks. The DON acknowledged that it was expected for physician orders to be followed and confirmed the ordered foot care was not provided as required.
The facility's Legionnaires Water Management Program lacked essential procedures, control limits, monitoring protocols, and intervention strategies to prevent the introduction and spread of Legionella in the water system. Leadership, including the Administrator, DON, and Infection Control Preventionist, were unaware of these deficiencies, potentially affecting all residents.
A resident with severe cognitive impairment and neurological disease was observed in the dining room with an actively bleeding hand wound, blood on his hands, face, and clothing, and was left to feed himself with bloody hands. Staff served his meal and walked away without addressing the bleeding, and the DON confirmed this was unacceptable and that the wound should have been cleaned and covered.
Two residents were administered psychotropic and related medications, including antidepressants, anticonvulsants, antianxiety, and antipsychotics, without documented informed consent forms in their medical records. The DON confirmed that such consent should have been obtained and documented to ensure residents or their guardians were aware of the reasons, risks, and benefits of each medication.
Two residents were admitted with complex medical conditions, but the facility did not complete baseline care plans within 48 hours for one, and for the other, the care plan failed to address several key diagnoses such as dementia with psychotic disturbance, infection, and blindness. The DON confirmed these omissions and delays did not meet expectations for timely and comprehensive care planning.
A resident with blindness and depression did not have a care plan addressing activities, despite documented needs and expressed interest in participating in activities like bingo if assisted. The DON confirmed the Activities Department was responsible for this care plan, but it had not been developed. The resident was observed attempting to engage in activities without support.
The facility did not ensure the safe operation of essential kitchen equipment by failing to replace a broken plastic light cover over the stove. The dietary manager noted the cover had been broken since September 2023 and had not submitted a formal repair request, relying instead on verbal requests. The cover was held together with old, dirty tape, with a piece missing.
A facility failed to accommodate a resident's needs by not ensuring the call light was within reach and lacking signage in Navajo-Dine. The resident, with a history of falls, had the call light under the bed during multiple observations. A CMA confirmed the need for the call light to be accessible. Additionally, required signage in Navajo-Dine was missing, as confirmed by Social Services.
The facility failed to provide a home-like environment for 33 residents due to mice droppings found in various areas, including dining rooms and resident rooms. Staff reported the issue to management, but the problem persisted, indicating inadequate cleaning and pest control measures.
The facility failed to respect resident privacy and dignity by not knocking on bedroom doors before entering. A nurse entered a resident's room without knocking while the resident was asleep and later returned with a CMA, again without knocking. The nurse also entered another resident's room without knocking to perform personal care. The facility's policy requires staff to knock and announce their presence, but staff were in a hurry looking for supplies.
A facility failed to maintain infection control practices for a resident with a Foley catheter. Observations revealed that the resident's catheter bag was resting on the floor due to its attachment to the bed's bottom rail. A registered nurse confirmed that the catheter bag should not be on the floor.
Failure to Maintain Comfortable Temperatures and Provide Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not maintaining appropriate room temperatures for several residents and not providing bed linens for one resident. Surveyors observed that one resident was sleeping in a room that was noticeably colder than the common area, with the room thermostat set to 59°F and a wall furnace present but not functioning when the thermostat was adjusted. Another resident reported that his room was often cold despite the thermostat being set to 78°F. A third resident, sharing the cold room, was heard moaning in discomfort; a CNA stated this resident was moaning because she was cold and did not like being cold. Staff interviews revealed that CNAs and the Maintenance Supervisor believed the room thermostats did not work and that the 300-unit was often colder than other areas. The Maintenance Supervisor confirmed that room temperatures on the 300-unit were controlled by a thermostat at the nurse’s station, that he was aware of recent complaints, and that he did not keep logs of temperature readings. The RN and DON both acknowledged ongoing complaints about cold temperatures on the 300-unit, with the RN noting the nursing station vent constantly blew cold air and that residents had recently complained about cold rooms. The deficiency also includes the facility’s failure to provide bed linens for a resident with multiple chronic conditions, including atopic dermatitis, type 2 diabetes mellitus with diabetic neuropathy, varicose veins with inflammation, and unspecified dementia. This resident was repeatedly observed lying directly on a bare mattress without linens at multiple times throughout the same day. CNA staff reported that all CNAs are responsible for making resident beds and that beds should be re-made immediately after linens are removed. The RN stated that resident beds should be made without unnecessary delay, that residents should not lie directly on the plastic mattress surface because prolonged contact could disrupt the skin, and that residents can be cold without a blanket. The DON stated it was her expectation that all residents’ beds be made immediately after linens are removed and acknowledged that residents cannot rest comfortably without linens and that delays in making beds could contribute to worsening skin issues.
Incomplete MDS Cognitive Assessments for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete completion of the Minimum Data Set (MDS) cognitive assessment (Section C) for one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, a personal history of TIA and cerebral infarction without residual deficits, a cognitive communication deficit, and depression. These conditions were documented on the resident’s face sheet and establish that the resident had relevant cognitive and neurological history at the time the MDS assessments were due. Multiple MDS assessments for this resident, each with different assessment dates, showed repeated omissions and unanswered items in Section C (Cognitive Patterns). On one MDS, the item asking whether the Brief Interview for Mental Status (BIMS) should be conducted (C0100) was left unanswered, and all BIMS items (C0200–C0500) were unanswered, resulting in no BIMS score, while the staff assessment for mental status (C0600) was also dashed. Despite these omissions, short-term memory (C0700) and cognitive skills for daily decision making (C1000) were coded as “memory ok” and “modified independence.” On subsequent MDS assessments, C0100 was sometimes coded “yes,” but the BIMS items (C0200–C0500) were dashed, C0600 remained dashed, and short-term and long-term memory items (C0700, C0800) were also dashed, again resulting in the absence of a BIMS score. Across several MDS assessments, this pattern of incomplete coding persisted: key cognitive assessment items were either left unanswered or dashed, including the decision to conduct BIMS, the BIMS questions themselves, the staff assessment for mental status, and memory items. During an interview, the MDS Coordinator stated she was responsible for completing these MDS assessments for the resident and acknowledged that it was her expectation that the assessments, including Section C, be fully completed and not dashed or left unanswered. The documented record review and the MDS Coordinator’s statements together show that the facility did not ensure an accurate and fully completed MDS cognitive assessment for this resident.
Failure to Provide Ordered Diabetic Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered diabetic foot care for one resident with multiple high-risk conditions. The resident was admitted with Type 2 diabetes mellitus with diabetic autonomic neuropathy, paraplegia, cognitive communication deficit, reduced mobility, and unsteadiness on feet. Review of the resident’s care plan dated 08/05/25 showed that diabetic foot care was not included. A physician order dated 09/11/25 directed daily diabetic foot care and checks, including observation of the feet, toes, ankles, and soles for alterations in skin integrity, color, temperature, and cleanliness, inspection of shoes for proper fit and excessive wear, and checking pedal pulses every night shift. Review of the Treatment Administration Record from 09/11/25 through 01/14/26 revealed that the ordered diabetic foot care was not completed by nursing staff for the entire period reviewed. A podiatry consultation on 01/14/26 documented diagnoses of Type 2 diabetes mellitus with hyperglycemia, onychogryphosis, nail dystrophy, pain in both toes, localized edema, and slightly diminished range of motion in the foot and ankle joints without pain. The podiatrist performed debridement and trimming of thickened, painful toenails and recommended daily foot checks, supportive shoes, and moisturizing lotions with precautions. During an interview on 01/22/26, the DON stated it was her expectation that physician orders, including diabetic foot care, be followed and confirmed that the ordered foot care for this resident was not followed as prescribed.
Inadequate Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement an adequate Legionnaires Water Management Program (LWMP) as part of its infection prevention and control program. Record review showed that the LWMP, last revised in June 2020, lacked essential procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system. The policy did not specify control limits or parameters, did not include monitoring procedures or documented environmental testing protocols for Legionella, and did not establish acceptable control limits for the measures being monitored. Additionally, there were no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case in the facility. During an interview with facility leadership, including the Administrator, DON, Corporate Nurse, Corporate Maintenance Director, and the Infection Control Preventionist, it was revealed that they were unaware of the inadequacies in the LWMP. They did not know that the plan lacked procedures for control measures, acceptable control limits and parameters, monitoring procedures, testing protocols, or established interventions for non-compliance or cases of legionellosis. These failures had the potential to affect all residents in the facility.
Failure to Provide Dignified Care for Resident with Active Bleeding Wound
Penalty
Summary
A resident with a history of cognitive communication deficit and degenerative disease of the nervous system, and who was assessed as having severe cognitive impairment, was observed sitting in the dining room during lunch with an actively bleeding wound on his right hand. The resident had blood on both hands, his face, and clothing, and was seen feeding himself with his bloody hands, including picking butter out of single-serve butter cups. Staff served the resident his meal tray and then walked away without addressing the bleeding wound or cleaning the resident. The Director of Nursing confirmed that the resident had an open, actively bleeding wound and blood on his hands and clothing, and acknowledged that it was not acceptable for the resident to be in the dining room in that condition. The DON stated that the wound should have been cleansed and covered, and that staff should have attended to the resident's wound before serving his meal. The failure to provide care with dignity and respect was directly observed and verified during the survey.
Failure to Obtain and Document Informed Consent for Psychotropic and Related Medications
Penalty
Summary
The facility failed to ensure that residents or their guardians were fully informed about the medications they were receiving, including the reasons for use, risks, and benefits. For two of three residents reviewed for unnecessary medications, there was no documentation in the electronic medical record of signed consent forms for prescribed medications such as antidepressants, anticonvulsants, antianxiety, and antipsychotic drugs. Specifically, one resident was prescribed Escitalopram, Depakote, Quetiapine, and Hydroxyzine for conditions including depression, anxiety related to traumatic brain injury, and agitation, but no consent forms were found in the record for any of these medications. Similarly, another resident was prescribed Citalopram and Hydroxyzine for depression and anxiety related to dementia, but again, no signed consent forms were present in the medical record. During interviews, the DON confirmed that there should have been signed consent forms for these medications. The lack of documented consent indicates that residents or their responsible parties were not adequately informed about the medications being administered.
Failure to Develop and Implement Timely and Comprehensive Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement adequate baseline care plans within 48 hours of admission for two out of three residents reviewed. For one resident with multiple complex diagnoses, including urinary tract infection, diabetes, depression, blindness, and traumatic brain injury, the baseline care plan was not completed until four days after admission, exceeding the required 48-hour timeframe. This delay was confirmed by record review and interview with the Director of Nursing, who acknowledged the care plan should have been completed within the specified period. For another resident with a history of cerebrovascular disease, Klebsiella pneumoniae infection, anemia, diabetes, hyperlipidemia, dementia with psychotic disturbance, blindness, hypertension, chronic kidney disease, and urinary tract infection, the baseline care plan developed did not address several critical conditions, including dementia with psychotic disturbance, Klebsiella pneumoniae, blindness, and sequelae of cerebrovascular disease. The Director of Nursing confirmed that these conditions should have been included in the baseline care plan and that it is her expectation for care plans to be both timely and comprehensive.
Incomplete Care Plan for Resident with Blindness and Depression
Penalty
Summary
The facility failed to ensure a comprehensive care plan was complete for one resident with diagnoses of blindness and depression. Record review showed that, despite the resident's admission and documented needs, there was no care plan addressing activities for this individual. Interviews revealed that the resident listens to music and TV for entertainment, would participate in bingo if assisted, and walks in the hallway to stay occupied. The DON confirmed that the Activities Department is responsible for creating such care plans and was unsure why one had not been developed. Observations showed the resident attempting to engage in activities, such as entering a bingo game but leaving after not receiving assistance.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition by not replacing a broken plastic light cover located directly over the cooking area of the stove. During an initial tour of the kitchen, it was observed that the light in the stove hood had a broken plastic cover, with tape holding part of it together, and a piece of the cover was completely missing. The tape was hanging loosely and appeared old and dirty. In an interview, the dietary manager revealed that the light cover had been broken since he started working at the facility in September 2023. He admitted that he had not submitted a formal work order to repair or replace the light cover, although he had verbally requested the repair. The dietary manager was uncertain about if or when the light cover would be repaired, confirming the presence of loose and dirty tape holding the cover together.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs, specifically regarding the accessibility of the call light and the availability of signage in the resident's preferred language, Navajo-Dine. Observations revealed that the resident's call light was consistently out of reach, being found under the bed on multiple occasions. This was confirmed by a Certified Medical Assistant who acknowledged the resident's need for assistance and the importance of having the call light within reach due to the resident's history of falls. Additionally, the care plan indicated that signage should be available in both English and Navajo-Dine, but observations showed a lack of such signage in the designated area, which was confirmed by Social Services.
Facility Fails to Maintain a Home-like Environment Due to Mice Infestation
Penalty
Summary
The facility failed to maintain a comfortable and home-like environment for all 33 residents, as evidenced by the presence of mice droppings in multiple areas of the facility. Observations conducted on various dates revealed mice droppings in the main conference room, main dining area, secondary dining area, and several resident rooms in the 400 hall. These findings indicate a lack of adequate cleaning and pest control measures, which are essential for ensuring a safe and comfortable living environment for the residents. Interviews with staff members, including a Certified Medical Assistant and a housekeeper, confirmed the presence of mice and their droppings throughout the facility. The staff reported that they had informed management about the issue, and the housekeeper mentioned that she attempts to clean the droppings daily. Despite these efforts, the problem persisted, suggesting that the facility's current cleaning and maintenance practices were insufficient to address the infestation effectively.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy by not knocking on their bedroom doors before entering. This deficiency was observed in the interactions involving two residents. During an observation, a Registered Nurse (RN) entered a resident's room without knocking while the resident was asleep. The RN also entered multiple empty rooms without knocking and later returned to the same resident's room with a Certified Medical Assistant (CMA), again without knocking. In another instance, the RN entered a different resident's room without knocking to perform personal care. An interview with the CMA revealed that the facility's policy requires staff to knock and announce their presence before entering a resident's room, but the staff were in a hurry looking for supplies for another resident.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who was reviewed for catheter care. During observations on two consecutive days, it was noted that the resident's urine catheter bag was improperly positioned, resting on the floor due to its attachment to the bottom rail of the bed, which was in the lowest position. This improper positioning of the catheter bag was confirmed by a registered nurse, who acknowledged that the catheter bag should not be resting on the floor.
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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