Life Care Center Of Farmington
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, New Mexico.
- Location
- 1101 West Murray Drive, Farmington, New Mexico 87401
- CMS Provider Number
- 325103
- Inspections on file
- 22
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Life Care Center Of Farmington during CMS and state inspections, most recent first.
A resident with Parkinson’s disease had an active order for carbidopa-levodopa four times daily and a care plan instruction that the resident’s son be notified of any medication changes or behaviors. Nursing staff placed the Parkinson’s medication on hold to assess behaviors and, after the resident developed weakness and arm shaking, the physician ordered a reduced dosing schedule. The resident reported not knowing the medication had been stopped until his hands began shaking, and the son, identified as POA, stated he was not informed of the discontinuation or change despite the care plan directive. The Administrator confirmed that the son should have been notified before altering the resident’s Parkinson’s medication and that this did not occur.
Staff failed to secure medication carts and left pre-poured medications unattended in resident care areas, including narcotics, in violation of facility policy. A nurse and a certified medication aide admitted to leaving medications accessible and unsupervised, with the aide reporting this occurred regularly. The DON confirmed these actions were not permitted and that only licensed staff are responsible for medication administration.
The facility did not follow its infection prevention policy by allowing symptomatic staff, including a CNA and a housekeeper, to work while ill, which contributed to a COVID-19 outbreak affecting all residents on a unit. The outbreak resulted in widespread resident infections and required prolonged isolation precautions, as the facility failed to effectively identify and control the spread of infection.
A resident with documented mental health diagnoses, including anxiety disorder, major depressive disorder, and ADHD, was admitted without an accurate PASARR screening. The PASARR form was incomplete and did not reflect the resident's mental health conditions, despite documentation in the care plan and medication records. Staff interviews confirmed the form was not properly completed or reviewed, and that PASARR responsibilities were shared between Admissions and Social Services.
A resident with multiple mental health diagnoses did not receive the full prescribed taper of Venlafaxine during a cross-taper to another antidepressant due to pharmacy supply and insurance issues. The facility failed to ensure the medication was available and administered as ordered, resulting in the resident missing several days of therapy and experiencing increased anxiety and distress. The DON and providers confirmed lapses in communication and medication administration.
A resident with severe dementia had a religious item removed from their room by a priest without prior authorization from the resident's POA. The priest claimed to have asked the resident for permission, but the resident was not capable of providing informed consent. Facility leadership confirmed that removal of personal items without proper authorization was not permitted, and the POA was not notified before the item was taken.
A resident with multiple mental health diagnoses repeatedly requested access to her medical records, both directly and through the State Ombudsman, but did not receive the records or a written denial. Facility staff, including the DON and MRD, were unclear about what information was included in the medical record and did not process the request within the required timeframe, resulting in a failure to comply with policy and federal requirements.
A resident with depression and anxiety did not receive prescribed doses of Venlafaxine for several days, and the facility failed to promptly notify the MD about the missed medication. The lapse in communication was confirmed by both the DON and MD, and the resident experienced suicidal thoughts during the period without medication.
Surveyors found that food items in the kitchen's dry storage and refrigerator were left opened, undated, and unprotected, while the kitchen itself was unclean with food debris and stains on surfaces and equipment. Single use items were stored unprotected near sinks, and staff did not consistently wear hairnets or beard guards as required. Additionally, the ice machine was improperly drained, with the drain pipe discharging below the floor and the hand washing sink draining onto it, leading to visible contamination.
A resident with hypertension, diabetes, and dementia did not receive prescribed doses of carvedilol on multiple occasions because the medication was not available and staff had inconsistent access to the emergency medication kit. Staff interviews confirmed the medication was ordered but not delivered, and there was confusion about who could access the eKit to obtain the needed medication.
Staff did not secure the E-cart containing scissors, IV catheters, and oxygen tubing, leaving it accessible to unattended residents in the day room. The shower room was also left unlocked with shaving razors and bleach cleaner stored inside, while residents walked by unsupervised. Interviews revealed staff were unaware or did not follow protocols to lock these areas and items, as confirmed by the DON.
Nurses and CMAs did not consistently date, label, or discard opened insulin pens within the required 28-day period, resulting in multiple instances where insulin pens were either undated, unlabeled, or not discarded as per policy. Staff interviews confirmed the expectation to follow these procedures, but observations showed noncompliance, affecting three residents who had active orders for Insulin Lispro.
A resident with multiple chronic conditions was assessed using the MDS, which incorrectly listed English as the primary language despite staff and social services confirming the resident primarily spoke Navajo. Staff interviews revealed that translation was often needed, and cognitive assessments conducted in Navajo yielded higher scores than those in English, highlighting the inaccuracy in the MDS documentation.
A resident with multiple diagnoses, including diabetes, dementia, and hypertension, was ordered to receive continuous oxygen therapy, but the care plan did not address this treatment. The DON confirmed that oxygen use should have been included in the care plan.
A resident with multiple medical conditions and a physician's order for continuous oxygen therapy was observed not wearing her oxygen as prescribed, including instances where the oxygen concentrator was off or the resident was not using the device during activities. Staff and the medical director confirmed that the resident should have been on continuous oxygen per the current order.
Staff did not recognize that exit doors in the Memory Unit failed to unlock when the fire alarm was activated, and this malfunction was only discovered during a fire alarm test. The Administrator was unaware of the issue until after the test, and the deficiency was not identified through the facility's QAPI process.
A resident who required staff assistance for ADLs did not receive scheduled showers for a week, and staff failed to document the reason for the missed care or provide follow-up notes. The lapse was identified after the resident's family raised concerns, and the DON confirmed both the missed showers and lack of documentation.
A facility failed to notify a resident's POA of medication changes, including increased dosages of Buspirone and Trazodone, for a resident with Alzheimer's, anxiety, depression, and dementia. The POA was unaware of these changes until after discharge, and the facility did not document consent or notification, as confirmed by the DON and Nurse #1.
A facility failed to ensure nursing staff had the necessary competencies, resulting in severe harm to two residents. One resident suffered a fatal fall due to improper assistance during a brief change, while another experienced improper catheter management and was injured further by staff pulling on his arm to assist him in standing, despite his complaints of pain. These incidents highlight significant gaps in staff training and adherence to care plans.
A resident with multiple health issues, including muscular dystrophy and obesity, fell from her bed and later died after a CNA attempted to change her brief alone during a shift change. The CNA moved the bed away from the wall, contrary to standard practice, and asked the resident to roll onto her side. The resident fell, sustaining injuries that led to her death. Other CNAs confirmed that two-person assistance was standard for such tasks, and the Director of Nursing acknowledged the deviation from standard practice.
Two residents in a LTC facility experienced inadequate pain management and assessment. One resident, with multiple fractures, was improperly handled by staff despite visible pain, while another resident suffered severe knee pain after a shower incident and was left in distress for hours before being sent to the hospital, where bilateral femur fractures were discovered. The facility's staff failed to follow proper protocols for pain assessment and management, highlighting deficiencies in training and communication.
A resident with multiple health issues, including neuromuscular dysfunction of the bladder, had a catheter leg bag improperly managed by staff, leading to potential infection risks. Despite physician orders to keep the catheter below bladder level, staff placed the leg bag on the resident while in bed, risking urine backflow. Observations and interviews confirmed this practice, highlighting a lapse in infection prevention measures.
The facility failed to ensure residents were treated with respect and dignity during dining. Observations revealed CNAs and a nurse standing while feeding residents, contrary to the facility's expectation for staff to sit during mealtime assistance. Interviews confirmed awareness of this practice by the Administrator and DON.
A resident suffered bilateral femur fractures after reportedly being dropped by a staff member during a shower. The facility failed to investigate the incident or report it to the State Agency. The DON only spoke briefly with the CNA involved and did not consult the LPN on duty. The Administrator did not consider it an injury of unknown origin, leading to no investigation or report submission.
The facility failed to report unwitnessed falls resulting in injury to the State Survey Agency for two residents. One resident experienced two falls resulting in abrasions, hematomas, lacerations, and bruising. Another resident experienced two falls resulting in abrasions and a hematoma. The facility did not submit Facility Incident Reports for these incidents, as the DON explained that they did not result in serious injury.
The facility failed to include current fall prevention strategies in the care plans of two residents. Despite being used as an intervention, placing the residents at the nurse's station for increased observation was not documented in their care plans. The DON confirmed the omission and was uncertain if it should be included.
The facility failed to ensure all medication carts were locked when not in use. An unlocked and unattended medication cart was observed on A hall, with the nearby nurses' station also vacant. An LPN confirmed the cart should have been locked, potentially affecting all 35 residents in A hall by allowing unauthorized access to medications and personal health information.
Failure to Notify Resident Representative of Parkinson’s Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant medication change as directed by the resident’s care plan. The resident, who had a diagnosis of Parkinson’s disease and an active order for carbidopa-levodopa 25/100 mg, two tablets by mouth four times daily, had a comprehensive care plan dated 02/28/24 instructing staff to notify the resident’s son of medication changes and behaviors. Nursing progress notes documented that on 11/10/2025 staff placed the resident’s carbidopa-levodopa on hold for seven days to assess for improvement in behaviors, and on 11/11/2025 the resident developed weakness and upper extremity shaking after the medication was held, leading the physician to order the medication at a reduced dose of 0.5 mg four times daily due to worsening symptoms. The record also showed that during a later meeting, the resident’s son expressed concerns that he had not been informed of the recent change to the Parkinson’s medication and the side effects that occurred after it was discontinued. In interviews, the resident stated he was unaware that the facility had stopped administering his carbidopa-levodopa until his hands began to shake aggressively, which bothered him. The resident’s son, identified as the resident’s POA, reported that the facility stopped the Parkinson’s medication, which had been given four times daily, and that he only learned of the discontinuation afterward, prompting him to contact the facility to ask why it had been stopped. He stated staff told him the medication was stopped to see if this would improve the resident’s behaviors and confirmed that the facility knew they were to notify him prior to any medication changes, but he was not contacted about the carbidopa-levodopa being stopped. The Administrator acknowledged that, because the care plan directed staff to notify the son regarding medication changes or behaviors, staff should have notified him prior to any changes and confirmed that the son was not notified before the Parkinson’s medication management was altered.
Unsecured Medication Carts and Unattended Pre-Poured Medications
Penalty
Summary
Facility staff failed to properly secure and administer medications for all 112 residents listed on the census. Observations revealed that medication carts were left unlocked and unattended in hallways, providing unsupervised access to resident medications, including narcotic controlled substances. Additionally, staff were found to have pre-poured medications into unlidded cups and left them unattended on tables in resident care areas, with no licensed nurse present to supervise. These actions were in direct violation of the facility's medication administration policy, which requires medications to be prepared for one resident at a time, not to be pre-poured, and to remain secured and attended at all times. Interviews with staff confirmed these practices. A registered nurse acknowledged responsibility for keeping the medication cart locked and recognized that leaving it unsecured allowed unauthorized access to medications. A certified medication aide admitted to pre-pouring medications for multiple residents and leaving them unattended while assisting another resident, stating that this occurred once or twice a week. The aide also confirmed that the facility's policy prohibits pre-pouring and leaving medications unattended, and that staff are required to ask another qualified staff member to monitor medications if they must step away. The Director of Nursing confirmed that the facility does not permit pre-pouring medications or leaving them unsecured and unattended. She stated that only licensed individuals are responsible for medication administration and that certified nurse aides are not permitted to supervise medications. The DON acknowledged that leaving pre-poured medications unattended is unacceptable and creates significant risk, as staff would not know whose medications they were and residents or visitors could access them.
Removal Plan
- The identified CMA will not pass medications until further determination is made.
- The DON/designee checked all other medication carts to determine if there were any other pre-poured medications. No other instances of pre-poured medications were observed.
- The DON/designee checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- The DON/designee monitored residents on identified hall who received pre-poured medications, no concerns were identified. They were monitored for potential adverse medication reactions, such as a significant change in vital signs. No concerns were identified.
- Education was provided to all nurses and CMAs on-site regarding: Medications are to only be prepared for one resident at a time, using a 3-way-check (comparing the medication to the MAR and to the prescription label).
- No pre-poured medications are allowed.
- Medications are not to be left unsecured and unattended.
- Medication carts will be locked at all times when out of site or unattended.
- Nurses and CMAs that are coming in as scheduled, will receive education prior to passing any medications.
- Additional Nurses and CMAs that are not onsite will receive education via telephone and a signed acknowledgement of education will be obtained prior to their next working shift.
- Record review of new admissions audit to ensure accurate medication reconciliation, review and continuation of medications and treatments.
- Record review of staff signature sheets for checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- Interviews with nurses regarding in-services and on pre-pouring medication and leaving medications unsecure.
- Interview with the Administrator and DON regarding plan of removal, audits, and medication reconciliation processes.
Failure to Exclude Symptomatic Staff Led to COVID-19 Outbreak
Penalty
Summary
The facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) during a COVID-19 outbreak that affected all 58 residents on Unit A. According to the facility's IPCP policy, staff with communicable diseases were to be excluded from resident contact, and a system for staff to report illness and remain off work while symptomatic was required. However, record review and interviews revealed that symptomatic staff, including a Certified Nurse Aide and a housekeeper, continued to work while ill, which contributed to the onset and spread of the outbreak. The facility did not effectively identify and control the spread of infection, resulting in unit-wide clustered transmission and prolonged isolation precautions for residents. The Infection Preventionist confirmed that the outbreak began when symptomatic staff worked while sick, and that testing was conducted every three days until all residents tested negative. The Administrator acknowledged awareness of the outbreak and confirmed that staff and residents were repeatedly tested as new cases emerged. Despite these measures, the failure to exclude symptomatic staff from resident contact and to control the spread of infection led to many residents becoming symptomatic and required the isolation of all residents in their rooms due to ongoing transmission.
Failure to Accurately Complete PASARR Screening for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for a resident with multiple mental health diagnoses. Record reviews showed that the resident was admitted with diagnoses including anxiety disorder, major depressive disorder, and ADHD. Despite these diagnoses, the PASARR form completed for the resident was inaccurate: Section A, which identifies the type of review, was left blank, and Section C, which should list mental illness evaluation criteria, was marked 'No' and did not include the resident's mental health diagnoses. The resident's Minimum Data Set and care plan both documented the use of antidepressant medication for depression, further confirming the presence of mental health conditions that should have been reflected in the PASARR. Interviews with facility staff revealed that the Admissions Director acknowledged the PASARR was incorrect and did not align with the resident's medical orders. The Social Services Assistant stated she was familiar with the PASARR process but had not received formal training and was not involved in the completion or review of the resident's PASARR. The Administrator and Social Services Director both confirmed that PASARR responsibilities are shared between Admissions and Social Services, and both agreed that the PASARR for this resident was not completed accurately, as required.
Failure to Provide Complete Prescribed Medication Taper
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety disorder, major depressive disorder, and ADHD did not receive the full provider-ordered taper of Venlafaxine during a cross-taper process to another antidepressant. The facility failed to obtain and administer the complete medication regimen as ordered, resulting in an unintended interruption of therapy. Record review showed that the resident did not receive Venlafaxine for a period of several days, and this lapse was due to the pharmacy only providing the first week of the taper and failing to supply the second week because of insurance-related issues. The facility did not ensure the medication was available or administered as prescribed. Interviews with the DON confirmed that the resident went approximately one week without the prescribed medication, leading to increased anxiety and distress. The DON acknowledged that the facility is responsible for ensuring residents receive all prescribed medications regardless of insurance or pharmacy barriers. The resident's medical doctor and psychiatric provider both confirmed they were not notified in a timely manner about the missed doses, and the psychiatric provider noted the resident experienced emotional distress and physical symptoms during the period without medication.
Failure to Honor Resident Choice and Secure Authorization for Removal of Personal Religious Item
Penalty
Summary
A deficiency occurred when an outside individual, specifically a priest, entered the room of a resident with severe cognitive impairment and removed a religious item without obtaining authorization from the resident's Power of Attorney (POA). The resident, who had diagnoses including dementia, Parkinson's Disease, and a history of intracerebral hemorrhage, was assessed as having severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 03. The priest claimed to have asked the resident for permission before removing the item, but the resident's POA stated that the resident was not capable of providing informed consent due to his dementia. The POA was not notified prior to the removal of the item, and the family believed the removal constituted theft. The incident was reported to the facility's Ombudsman, who also noted that the camera in the resident's room had been turned off for approximately eight minutes during the time of the incident. The Director of Nursing (DON) and the Administrator both confirmed that no one, regardless of their status, was permitted to remove personal items from a resident's room without proper authorization from the resident or their legal representative. The Administrator acknowledged that the situation should have been addressed through a care conference with the POA, but this did not occur.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to her medical records after multiple requests were made by both the resident and the New Mexico State Ombudsman acting on her behalf. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and ADHD, requested her medical records in the first week of July from several staff members, including nurses, the DON, the Medical Records Director (MRD), and the Administrator (ADM). Despite these requests, the resident did not receive any part of her medical records, nor was she given a written explanation for the delay or denial. Documentation shows that the Ombudsman initially requested the records via email on July 1, with follow-up requests made in subsequent weeks. The facility's Health Information Management Manual states that requested copies should be provided within two working days, and that residents must receive a timely, written denial if access is denied. However, the records were not provided within the required timeframe, and no written denial was issued to the resident or her representative. Interviews with facility staff revealed confusion regarding what constituted the resident's medical record, particularly concerning pharmacy communications and medication information. The MRD and DON indicated that pharmacy information was not considered part of the medical record, and the ADM stated he was unaware of the initial request but expected records to be provided promptly. Despite these statements, the resident's requests remained unfulfilled, and the facility did not follow its own policy or federal requirements regarding access to medical records.
Failure to Notify MD of Missed Antidepressant Doses
Penalty
Summary
The facility failed to notify the Medical Director (MD) of missed doses of an antidepressant medication, Venlafaxine, for a resident diagnosed with anxiety disorder, major depressive disorder, and ADHD. The resident did not receive Venlafaxine for a period of seven days, as documented in the Medication Administration Record. During this time, the facility did not communicate the missed doses or the unavailability of the medication to the MD, despite the resident's ongoing mental health conditions and the prescribed medication schedule. The deficiency was confirmed through record review and interviews, which revealed that the DON acknowledged the MD was not informed of the missed doses, and the MD confirmed he was not notified until the second week of the missed medication. The resident subsequently experienced suicidal thoughts, which were documented in the provider's visit notes after the period without medication. The MD stated he would have taken steps to provide the medication sooner if he had been notified promptly.
Deficient Food Storage, Sanitation, and Staff Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service areas, as evidenced by multiple observations and record reviews. In the kitchen's dry storage and refrigerator, numerous food items such as granulated garlic, fruit cups, pizza slices, bread, seasonings, cereals, and prepared foods were found opened, undated, and in some cases unsealed or exposed to air. The facility's own food safety policy required all food items to be labeled, dated, and stored in a manner that protects them from contamination, but these procedures were not followed. The Dietary Manager confirmed that all food items should be labeled, dated, and protected from air and contamination. The kitchen environment was observed to be unclean, with stains and spatters on the walls, food particles on the microwave, black debris around stove burners, white splashes on the oven, buildup on baseboards, and crumbs and splatter on food preparation surfaces. A sugar container was found with a lid that did not fit and brownish debris inside. The facility's cleaning schedule required daily cleaning of these areas, but these tasks were not completed as required. Additionally, single use items such as cloth napkins and Styrofoam plates were left exposed and unprotected near the hand washing sink, contrary to the Dietary Manager's statement that such items should be protected and stored away from potential contamination sources. Staff were also observed not adhering to personal hygiene standards, with one staff member not wearing a hairnet properly and another with facial hair not wearing a beard guard while working in the kitchen. The facility's food safety policy addressed the risk of physical contaminants such as hair but did not specifically require hairnets or beard guards. Furthermore, the ice machine was not properly drained through an air gap, with the drain pipe discharging below the floor surface and the hand washing sink draining onto the ice machine drain pipe, resulting in a black substance around the pipe. The Dietary Manager was unaware of these drainage issues, which were not addressed in the facility's policy.
Failure to Administer Ordered Medication Due to Unavailable Supply and Access Issues
Penalty
Summary
The facility failed to provide care that met professional standards for one resident by not obtaining and administering carvedilol as ordered by the physician. The resident, who had diagnoses including type II diabetes, dementia, and hypertension, was admitted with a physician's order for carvedilol to be given twice daily for hypertension. Record review showed that the medication was not administered on several occasions because it was not available, as documented in the Medication Administration Record and nursing progress notes. Staff interviews revealed that the carvedilol had been ordered from the pharmacy, but it was not delivered. The Certified Medication Technician reported checking on the medication status daily and attempting to access the emergency kit (eKit) for the medication, but did not have access and had to rely on nurses to obtain it. There was inconsistency among staff regarding access to the eKit, with some nurses able to access it and others losing access if they did not log in regularly. The Director of Nursing confirmed that any nurse could pull medication from the eKit, but if access was lost, another nurse should have been asked to assist.
Failure to Secure Emergency Cart and Shower Room Creates Accident Hazards
Penalty
Summary
Staff failed to ensure that the B Unit was free from accident hazards by not securing the Emergency Cart (E-cart) and the shower room. The E-cart, which contained scissors, IV catheters, and oxygen tubing, was found unlocked and accessible to residents in the day room, with several residents present and unattended by staff. The facility's E-cart policy did not address the need to lock the cart to prevent unauthorized access. Additionally, the shower room was left unlocked and unattended, with shaving razors and a bottle of Cloralen bleach cleaner stored in an unsecured vanity. Several residents were observed walking by the open shower room without staff supervision. Interviews with staff revealed a lack of awareness and adherence to safety protocols. A nurse stated she was unsure if the E-cart should be locked, while multiple CNAs acknowledged that the shower room should have been locked when not in use. The DON confirmed that both the E-cart and the shower room should be secured to prevent resident access to potentially hazardous items, and that the items found in both locations could pose risks to residents if left accessible.
Failure to Date, Label, and Discard Opened Insulin Pens as Required
Penalty
Summary
Nurses and Certified Medication Aides (CMAs) failed to properly date and discard opened insulin pens within the required 28-day period for three residents. Observations revealed that one insulin pen was opened and not dated, another was opened and dated but not discarded after 28 days, and a third was opened, undated, and unlabeled, making it impossible to identify the owner. The facility's policy and the manufacturer's instructions both require that opened multidose insulin pens be dated and discarded within 28 days, and that each pen be labeled with the resident's name upon first use. Interviews with staff, including a nurse, the Director of Nursing (DON), and the Consultant Pharmacist (CP), confirmed that the expectation is to date, label, and timely discard insulin pens. However, the observed practices did not align with these requirements, resulting in the potential for residents to receive insulin that was either expired or not properly identified. The records confirmed that the affected residents had active orders for Insulin Lispro.
Inaccurate MDS Assessment Due to Incorrect Primary Language Documentation
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for a resident with multiple diagnoses, including chronic respiratory failure with hypoxia, COPD, Parkinson's disease, and paroxysmal atrial fibrillation. The resident's face sheet indicated an admission date and listed these diagnoses. Multiple MDS assessments documented the resident's primary language as English. However, interviews with nursing staff, a CNA, and the Social Services Assistant revealed that the resident primarily spoke Navajo and understood Navajo better than English. Staff reported that they often needed to find a Navajo-speaking staff member to translate for the resident. Further, the Social Services Assistant, who spoke Navajo fluently, completed the resident's Brief Interview of Mental Status (BIMS) in English on one occasion, resulting in a score indicating moderate cognitive impairment. When the BIMS was later conducted in Navajo, the resident scored higher, suggesting better cognitive function when assessed in their primary language. The Social Services Director acknowledged that the discrepancy in BIMS scores was likely due to the language used during the assessment and confirmed that the MDS should have reflected Navajo as the resident's primary language.
Care Plan Not Updated for Oxygen Therapy
Penalty
Summary
The facility failed to update the care plan for a resident who was admitted with diagnoses including Type II diabetes, dementia, and hypertension. Physician orders dated 05/08/25 indicated that the resident required continuous oxygen at 2 liters per minute via nasal cannula, with instructions to maintain oxygen saturation above 90%. However, review of the resident's care plan showed that it did not address the use of oxygen therapy. During an interview, the DON confirmed that oxygen use should be included in the care plan if a resident is receiving it. This omission demonstrates that the care plan was not revised to reflect the resident's current treatment needs as required.
Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident with diagnoses including type II diabetes, dementia, and hypertension was admitted to the facility and had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula, with instructions to keep oxygen saturation above 90%. Record review showed that the resident's oxygen saturation dropped to 87% on room air and was at 90% when on 2 liters of oxygen, indicating a need for consistent oxygen therapy as ordered. Despite these orders, observations revealed that the resident was not consistently receiving oxygen as prescribed. On one occasion, the resident wore the nasal cannula, but the oxygen concentrator was not turned on. At another time, the resident was seen participating in activities without wearing the oxygen. Interviews with nursing staff and the medical director confirmed that the resident should have been on continuous oxygen per the physician's order, and that the order had not been changed to allow for discontinuation or intermittent use.
Failure to Identify Exit Door Malfunction During Fire Alarm Activation
Penalty
Summary
Facility staff failed to identify and address a malfunction in the exit doors of the Memory Unit, as the doors did not unlock when the fire alarm was activated. This issue was discovered during an observation when staff tested the fire alarm and found that all three exit doors remained locked. The Administrator confirmed in an interview that he was unaware of the malfunction until the fire alarm test was conducted, and stated that his expectation was for staff to have recognized the problem prior to the test. The deficiency was not identified through the facility's Quality Assurance and Performance Improvement (QAPI) process, indicating a lapse in the facility's ability to detect and address quality deficiencies related to emergency preparedness.
Failure to Provide Timely ADL Assistance and Documentation for Showering
Penalty
Summary
Staff failed to provide timely assistance with activities of daily living (ADLs), specifically showering, for one resident who required the help of one staff member for personal care. The resident was scheduled to receive showers on Wednesday and Saturday evenings, but did not receive a shower for a seven-day period. There was no documentation in the resident's medical record or care plan explaining the missed showers, nor any follow-up notes regarding the reason for the lapse. The issue was brought to the attention of the Director of Nursing after the resident's daughter expressed concern about the lack of showers over five days, and the Director confirmed the absence of both the showers and the required documentation.
Failure to Notify POA of Medication Changes
Penalty
Summary
The facility failed to notify the family member/Power of Attorney (POA) of a resident when changes in the resident's medication were made. The resident, who had been diagnosed with Alzheimer's disease, anxiety, depression, and dementia with psychotic disturbance, experienced changes in their medication regimen, including increases in dosages of Buspirone and Trazodone. However, there was no documentation in the resident's medical record indicating that the family or POA was informed of these changes, nor was there any record of verbal consent being obtained for the medication adjustments. Interviews with the family member/POA revealed dissatisfaction with the facility's communication, as they were unaware of the medication increases until after the resident's discharge. The family member/POA expressed concerns about the lack of notification and the inability to make informed decisions regarding the resident's care. The Director of Nursing confirmed that staff should have notified the family prior to any medication changes and documented the consent in the resident's medical record, which did not occur in this case. Nurse #1 acknowledged the medication increase was due to the resident's anxiety-related behaviors but admitted to not notifying the family member/POA.
Inadequate Staff Competency Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies to provide adequate care for two residents, resulting in severe consequences. One resident, who was dependent on staff for all activities of daily living due to conditions such as muscular dystrophy and obesity, suffered a fatal fall from the bed. The incident occurred when a CNA attempted to change the resident's brief alone, despite the care plan indicating the need for assistance from one or two staff members. The CNA moved the bed away from the wall and asked the resident to roll over, which led to the resident rolling off the bed and sustaining a serious head injury that resulted in death. Another resident experienced inadequate care related to catheter management and assistance with standing. The resident, who had multiple diagnoses including dementia and Parkinson's disease, was found to have his catheter leg bag positioned incorrectly while in bed, risking infection. Additionally, staff were observed pulling the resident by his right arm to assist him in standing, despite the resident's complaints of pain and visible bruising. This improper handling led to further injury, including a fractured clavicle and ribs, as confirmed by x-rays. Interviews with staff revealed a lack of specific training and awareness regarding the residents' care needs. The CNA involved in the fall with the first resident admitted to changing the resident alone due to shift change and being unaware of the proper procedures. Similarly, staff assisting the second resident were not informed of the extent of his injuries and continued to use inappropriate methods to help him stand, exacerbating his condition. These deficiencies highlight a significant gap in staff training and adherence to care plans, resulting in harm to the residents.
Removal Plan
- Resident #1 was discharged to the hospital.
- Resident #12 was reassessed by therapy to review level of assist for transfers. Staff working with Resident #2 were educated to follow the individual care plan that was updated on how to transfer safely with regards to his current fracture. Resident #2 was also reassessed regarding his catheter bag needs and the care plan was updated. Staff working with Resident #2 were educated to follow catheter needs as directed by care plan.
- An audit was completed by the DON and Infection Preventionist (IP) Nurse to ensure that all residents who require peri-care are care planned for level of assistance required with peri-care. All changes will be reflected in the Kardex for CNAs.
- An audit was completed by the DON and IP Nurse to ensure that all residents with current fractures are care planned for level of assistance required due to their injury. All changes will be reflected in the Kardex for CNAs.
- An audit was completed by the DON and IP Nurse to ensure that all residents with urinary catheter bags are care planned with catheter bag change instructions. All changes will be reflected in the Kardex for CNAs.
- Policies and procedures related to person centered care planning and resident rights were reviewed and utilized for education.
- Education of licensed nursing staff and CNAs related to providing peri-care per individual care planned needs will be completed. These staff will not be allowed to work until they have received the education which will be provided prior to the start of their shift.
- Education of licensed nursing staff and CNAs related to how to transfer a resident appropriately who have current fractures will be started. These staff will not be allowed to work until they have received their education and will receive education prior to the start of their shift.
- Education of licensed nursing staff and CNAs related to a resident's individualized catheter bag change needs will be completed to educate to follow the resident's care plans with regards to bag change needs.
- Medical Director was notified of the IJ.
- Root cause analysis completed and taken to QAPI.
- QAPI to be conducted.
Failure to Provide Adequate Supervision Leads to Resident's Fatal Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was dependent on staff for all activities of daily living. The resident, who had muscular dystrophy, obesity, chronic pain, a cardiac pacemaker, and disc degeneration, was unable to assist in movements such as rolling or sitting up. Despite this, a CNA attempted to change the resident's brief alone during a shift change, moving the bed away from the wall and asking the resident to roll onto her side. The resident fell from the bed, sustaining injuries that led to her death at the hospital later that day. The CNA involved in the incident stated that she typically changed the resident with another person but decided to proceed alone due to the busy shift change. She moved the bed away from the wall to access both sides, which was not standard practice, and asked the resident if she could hold herself on her side. The resident agreed, but during the process, she rolled off the bed and hit her head. The CNA immediately notified the nurse, and the resident was assessed and transferred to the hospital, where she later passed away. Interviews with other CNAs revealed that it was common practice to use two people for pericare, especially for residents who were unable to assist themselves. They stated they would not move the bed away from the wall without another person present. The Director of Nursing confirmed that moving the bed away from the wall was not standard practice and should not have been done without additional assistance. This incident highlights a failure in providing adequate supervision and care, leading to a tragic outcome.
Inadequate Pain Management and Assessment in LTC Facility
Penalty
Summary
The facility failed to adequately assess and manage the pain of two residents, leading to significant deficiencies in their care. Resident #1, who had multiple diagnoses including dementia, Parkinson's disease, and a history of falls, was subjected to improper handling by staff. Despite the resident's visible signs of pain and verbal complaints, staff continued to pull on his injured right arm to assist him in getting out of bed. This occurred even after the resident's Power of Attorney had notified the facility of the issue. Subsequent medical evaluations revealed that Resident #1 had sustained multiple fractures, including a communicated fracture of the distal clavicle and several rib fractures, which were not properly addressed by the facility staff. Resident #11, who also had dementia and other significant health issues, experienced severe pain after an incident in the shower. Despite her complaints of severe knee pain and visible distress, the facility staff delayed in providing adequate medical attention. The resident was left sitting in pain for several hours before being seen by a physician and subsequently sent to the hospital. At the hospital, it was discovered that Resident #11 had bilateral femur fractures, which required surgical intervention. The delay in addressing her pain and the lack of immediate medical evaluation contributed to the severity of her condition. The report highlights a lack of proper training and communication among the facility staff regarding the handling and pain management of residents with known injuries. Both residents experienced significant pain and distress due to the staff's failure to follow appropriate protocols for assessing and managing pain, as well as a lack of timely medical intervention. These deficiencies in care reflect a broader issue of inadequate staff training and awareness in handling residents with complex medical needs.
Failure to Maintain Proper Infection Control with Catheter Use
Penalty
Summary
The facility failed to maintain proper infection prevention measures for a resident with a leg catheter bag. The resident, who was admitted with multiple diagnoses including dementia, difficulty walking, communication deficit, intracerebral hemorrhage, type II diabetes, Parkinson's disease, and neuromuscular dysfunction of the bladder, had physician orders to change the catheter bag as needed for infection, obstruction, or when the closed system is compromised. The catheter was to be kept below the level of the bladder. However, observations and interviews revealed that staff did not adhere to these orders. A video review and interviews with staff and the resident's Power of Attorney indicated that the catheter leg bag was placed on the resident while he lay in bed, which could cause urine to back up into the bladder. The Power of Attorney reported seeing recordings of staff putting the leg bag on the resident early in the morning, and the resident remained in bed for hours with the leg bag at the same height as the catheter. This practice was confirmed by a CNA and the Director of Nursing, who acknowledged that failing to change the catheter leg bag when the resident was in bed could lead to a urinary tract infection.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during dining, as observed in three instances. During lunch, a CNA was seen standing and feeding two residents simultaneously, moving back and forth between them. Another CNA was also observed standing while feeding a resident. Additionally, a nurse stood while feeding a resident who was seated in a reclining chair, explaining that she did so to monitor other residents. Interviews with the Administrator and DON revealed that they were aware of the staff's practice of standing while feeding residents, although their expectation was for staff to sit when assisting residents with eating.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, which was not reported to the State Agency. The incident involved a resident who was reportedly dropped by a staff member during a shower, resulting in bilateral femur fractures. The resident's daughter was informed by the facility staff that her mother was fine, but later received a call from the hospital indicating the need for surgery due to the fractures. The resident subsequently suffered a stroke and passed away. The Director of Nursing (DON) admitted to not conducting an official investigation into the incident and only had a brief conversation with the Certified Nursing Assistant (CNA) involved, who claimed nothing unusual occurred. The DON did not speak with the Licensed Practical Nurse (LPN) on duty at the time. The facility's Administrator also confirmed that no investigation or five-day report was submitted, as he did not consider it an injury of unknown origin. This lack of action and reporting could potentially lead to residents going without necessary treatment and being exposed to further injuries.
Failure to Report Unwitnessed Falls Resulting in Injury
Penalty
Summary
The facility failed to report unwitnessed falls resulting in injury to the State Survey Agency for two residents. Resident #10 experienced two unwitnessed falls, one resulting in an abrasion on the right knee and a hematoma on the face, and another resulting in lacerations on the forehead and nose, as well as bruising and swelling on the left hand, wrist, and forearm. Resident #7 experienced two unwitnessed falls, one resulting in an abrasion on the left knee and another resulting in a hematoma on the right elbow and a laceration on the back of the head. The facility did not submit Facility Incident Reports for these incidents, as the Director of Nursing explained that they did not result in serious injury, such as a fracture or hospital admittance.
Failure to Include Fall Prevention Strategies in Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included current fall prevention strategies for two residents. For Resident #7, the care plan did not list placing the resident at the nurse's station for increased observation, despite this being a documented intervention used when the resident struggled to fall back to sleep. Similarly, for Resident #10, the care plan did not include the intervention of placing the resident at the nurse's station for increased observation, even though the resident was observed at the nurse's station and had a history of impulsive behavior leading to frequent falls. The Director of Nursing confirmed that this intervention was used for both residents but was not included in their care plans, and was uncertain if it should be included.
Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure all medication carts were locked when not in use. This deficiency was observed on A hall, where the medication cart was found unlocked and accessible at 3:52 pm. The cart remained unattended for five minutes, and the nearby nurses' station was also vacant during this time. During an interview, an LPN confirmed that the medication cart was hers and acknowledged that it should have been locked. This failure potentially affects all 35 residents in A hall by allowing unauthorized access to medications and personal health information.
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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