Silver City Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver City, New Mexico.
- Location
- 3514 Fowler Avenue, Silver City, New Mexico 88061
- CMS Provider Number
- 325091
- Inspections on file
- 30
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Silver City Care Center during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen refrigerator, freezer, and pantry were not stored under sanitary conditions, with multiple products lacking dates, covers, or proper sealing, and some bearing outdated dates. Undated or improperly stored items included butter blocks, Jello, pears, peanut butter bar dessert, sliced ham, baked pineapple cake, Salsbury steak, chicken patties, lemon meringue pie, pie crusts, and corn tortillas. The DM reported that staff are expected to date food upon delivery and opening, and to discard outdated items, but acknowledged that food without dates, without covers, not tightly sealed, and with outdated dates was present.
Surveyors found that care plans were not revised to reflect current MD orders and resident needs. One resident had an order for enteral feeding when oral intake was poor, but the feeding and related interventions were not added to the care plan. Another resident with thick, layered toenails had an order for regular nail checks and trimming, including documentation of refusals, yet the care plan did not address nail care or how staff manage the resident’s combative behavior during this care, as confirmed by a CNA and a UM. A third resident had an order for PRN O2 at 1–2 L/min via nasal cannula for low oxygen, but O2 therapy and interventions were missing from the care plan, which the Administrator acknowledged.
Surveyors found that performance evaluations were not completed as required for two CNAs. Review of personnel files showed that each CNA, hired more than several months earlier, had no documented performance evaluation. In an interview, the administrator confirmed that no evaluations had been completed for these CNAs, despite the facility’s expectation that CNA performance reviews be conducted at least annually.
Surveyors found that consultant pharmacist recommendations regarding psychotropic and antidepressant medications were not consistently followed by physicians, and when recommendations such as continuation at current dose or consideration of GDR were made, physicians did not document resident-specific benefit/risk analyses or rationales in the medical records. Several residents with dementia, agitation, depression, and anxiety were receiving atypical antipsychotics or escitalopram, and pharmacy reports repeatedly noted the increased risks associated with these drugs in dementia-related psychosis while recommending continuation or GDR. The DON acknowledged that the charts lacked specific benefit/risk analyses or rationales for not implementing GDR, despite her expectation that physicians would provide this documentation.
Multiple residents had inaccurate or incomplete documentation in their medical records, including one resident whose admission assessment incorrectly recorded them as edentulous despite visible broken teeth, two residents whose activity participation records lacked entries for church attendance and ordered one-to-one activities that staff reported were being provided, and another resident whose documented skin assessment stated there were no skin issues even though the resident had a visible elbow wound with an unchanged dressing. Staff interviews, including with the UM, AD, wound care nurse, and DON, confirmed that the documentation did not reflect the care and conditions actually observed.
A resident’s needs were not reasonably accommodated when the call light in the resident’s room was found hanging from a light fixture above the bed, approximately six feet from the floor, making it inaccessible. A CNA confirmed that the call light was positioned this way and that the resident could not reach it. The Administrator acknowledged that residents are expected to be able to reach their call lights.
Two residents did not receive accurate MDS assessments. One resident with visibly broken and discolored teeth, who reported needing multiple teeth pulled, was incorrectly coded on the admission MDS as edentulous. Another resident with a history of cerebral infarction had a CTA showing complete occlusion of one carotid artery and significant stenosis of the other, with corresponding diagnoses documented in a provider note, but these active vascular diagnoses were not entered on the subsequent Quarterly MDS. The MDS coordinator reported she had not been informed of the new diagnoses and that they should have been included.
A resident with a PEG tube had an active order for Jevity 1.2 via PEG four times daily, while a later order allowed a regular/liberalized pureed diet with nectar-thick liquids and supervised soft snacks. Staff interviews revealed that the resident had been eating all meals by mouth for an extended period and only received PEG feeding, if at all, when oral intake was less than half of the meal. The NP and DON confirmed that the physician’s order was never updated to reflect this current practice, resulting in a discrepancy between documented orders and actual care, and a failure to meet professional standards of practice.
A resident developed a right elbow wound after scraping it on a wheelchair wheel, and an LPN initially cleansed the area and applied a bandage. The wound was never documented in the medical record, and no wound assessment, provider or family notification, or wound care orders were completed. Days later, the resident was observed with a dressing falling off and dried blood, and reported the bandage had not been changed since the injury. The wound care nurse and DON confirmed they were unaware of the wound and that required processes for new wounds, including documentation and obtaining treatment orders, had not been followed.
A resident with chronic respiratory failure, COPD, and a tracheostomy had a physician’s order for an oxygen concentrator at 3 LPM, but surveyors twice observed the concentrator set at 4 LPM. The resident reported staff had increased the flow after a low oxygen saturation reading, yet there was no documentation of when the change occurred, no respiratory assessment supporting the adjustment, and no evidence that a provider was notified or new orders obtained. An LPN and the DON confirmed the lack of documentation and communication regarding the change in oxygen therapy.
A resident admitted to the facility did not receive routine dental services, including an annual oral exam and necessary dental care such as cleaning, fillings, or denture adjustments. The resident’s family member reported that the resident had not seen a dentist since admission and noted missing teeth. The resident confirmed she had not been to a dentist and stated she wanted to go. Social Services also confirmed that no dental visit had been arranged for the resident during her stay.
Surveyors found that two CNAs did not have any documented in‑service training hours in their employee files despite a facility expectation of at least 12 hours of annual in‑service education, including dementia care and abuse prevention. The administrator confirmed that there was no in‑service training documentation for these CNAs, resulting in a cited deficiency related to inadequate staff training to meet resident care needs.
Staff did not follow proper infection prevention protocols when a disposable isolation gown was left hanging in the hallway outside a room under COVID-19 precautions. An LPN confirmed the gown should have been discarded after use, and the DON stated that all PPE must be removed before exiting the resident's room. This failure occurred while a resident was isolated for COVID-19.
Surveyors observed that the kitchen griddle was missing all four control knobs, preventing proper adjustment of the gas burners. This issue was confirmed by the DM and affected the majority of residents who received meals from the kitchen.
The facility did not ensure resident privacy and confidentiality when a privacy curtain between two residents' beds remained off track for months, leaving a gap, and a paper towel with a resident's name and vital signs was left unattended in a hallway. Staff confirmed these lapses, and the DON acknowledged that protected methods should be used for recording resident information.
The facility did not update care plans for two residents to reflect current information, including a change in discharge plans for one resident and the addition of psychotropic medications for another. The care plans lacked necessary updates and interventions, as confirmed by the DON.
A resident with type 2 diabetes was found to have overgrown toenails and callused feet, with no evidence of toenail care or podiatry referral since admission. Staff confirmed that toenail care had not been provided and that a podiatrist was not available to the facility, resulting in a lack of appropriate foot care for the resident.
Staff failed to document required blood pressure and heart rate readings before administering certain medications to a resident with hypertension and atrial fibrillation, and entered an incorrect diagnosis on the medication administration record for another resident prescribed mirtazapine. The Director of Nursing confirmed these documentation errors, resulting in incomplete and inaccurate medical records.
A resident who needed partial to moderate assistance with personal hygiene was observed to have overgrown and jagged fingernails. The resident stated that staff had not offered to cut her fingernails and she did not have clippers to do it herself. A CNA confirmed the resident's fingernails had not been cut.
A facility failed to investigate an abuse allegation involving a deceased resident. RN #1 used the deceased resident in a prank on NA #1, who was instructed to take the resident's vitals as a joke. The facility did not recognize this as abuse, and the Administrator was unaware of the prank until informed by NA #1's family. The incident was not reported to the state, and RN #1 was not immediately removed from duty. The facility's lack of action resulted in an Immediate Jeopardy situation.
A facility failed to recognize the mistreatment of a deceased resident when an RN instructed an NA to take vital signs as part of a prank. The NA, upon discovering the resident was deceased, experienced a panic attack. The Administrator did not initially report the incident as mistreatment, believing it was a staff issue. The RN received a reprimand, but no corrective action was taken regarding the respect of deceased residents.
A facility failed to respect a resident's dignity when a nurse used the deceased resident to play a prank on a nursing assistant. The nurse instructed the assistant to take the vital signs of the deceased resident, causing distress. The incident was known to several staff members, and the administrator initially misunderstood it as a teaching opportunity. The resident's family expressed disgust over the disrespectful act.
The facility failed to provide timely written transfer notices for four residents who were hospitalized for various reasons, including falls, abnormal lab results, and altered mental status. The DON confirmed the absence of these notices, which should have been completed at the time of transfer or as soon as practicable.
The facility did not provide written notices of the bed hold policy to residents or their representatives during hospital transfers. This affected four residents who were transferred for various medical reasons, and their records lacked the required notices. The DON confirmed the absence of these notices and was unsure of the timing for providing them.
The facility failed to update care plans for three residents who refused certain care activities, such as showers, blood glucose checks, and teeth brushing. The care plans lacked documentation of these refusals and did not include interventions to address them, despite staff being aware of the issues.
The facility failed to provide adequate ADL assistance for three residents, particularly in oral care and bathing. One resident, requiring substantial assistance, missed several scheduled showers, with no documentation explaining the omissions. Another resident, dependent on staff for showers, was cooperative but still missed scheduled showers. A third resident, also dependent, received minimal showers and inconsistent oral care, with the DON confirming the lack of documentation and adherence to care schedules.
The facility failed to follow physician orders for two residents, one of whom was not weighed weekly as required, despite being underweight. Another resident did not receive insulin as prescribed, with missing blood glucose documentation and no notification to the physician when insulin was held. This lack of adherence to orders could have impacted the residents' health monitoring and management.
The facility failed to follow its policies on food handling, staff attire, and hand hygiene, affecting 56 residents. Observations revealed undated food items, improper use of beard covers and hair nets, and inadequate handwashing practices. Staff were seen performing tasks with the same gloves without washing hands, and incorrect handwashing techniques were demonstrated.
A facility failed to complete a resident's quarterly MDS assessment within the required timeframe. The resident, with conditions including hypertension and diabetes type II, had an overdue assessment that was not completed due to a lapse in the automatic scheduling system. The MDS Coordinator confirmed the assessment was past due by over 120 days.
A facility failed to complete and transmit a quarterly MDS assessment for a resident with hypertension and diabetes type II within the required timeframe. The assessment, due 92 days after the previous one, was delayed by 120 days. The MDS Coordinator confirmed the oversight, noting that assessments are scheduled automatically in the Point Click Care System.
A facility failed to update a resident's PASARR Level 1 Screening after new diagnoses of bipolar disorder and major depressive disorder were added. The Admissions Coordinator was unaware of the changes and relied on the DON for updates. PASARR personnel confirmed a re-screening was necessary.
A resident with dementia and unsteadiness experienced multiple falls, but the facility failed to update the care plan with preventative interventions. Despite documented falls and a decline in cognitive function, the care plan remained unchanged since August 2022. Facility policies required intervention adjustments, but these were not implemented.
The facility failed to maintain clean oxygen concentrator filters for two residents, one with heart failure and another with COPD, as observed during multiple inspections. The filters were found to be heavily debris-laden and dirty, contrary to the facility's policy requiring weekly cleaning. The DON and UM acknowledged the issue, indicating a lack of clarity on cleaning responsibilities.
The facility did not fill in the daily census on the GenSTAR Daily Nurse Staffing Form, which is posted in a conspicuous area. This omission was observed on multiple occasions, potentially causing uncertainty for visitors about the staff-to-resident ratio. The Administrator confirmed that the census should have been indicated on the form.
A facility failed to maintain complete and accurate medical records for a resident, as staff did not document meal intake over several days. Despite a CNA stating the resident had not eaten for a week, the records lacked documentation of this issue. The DON confirmed the absence of necessary documentation.
The facility failed to store and serve food under sanitary conditions for 77 residents. Six frozen hamburger patties were found sitting on top of a microwave without proper containment, and the Dietary Manager was observed not wearing a facial hair covering or hairnet. The DM confirmed these lapses in food safety practices.
The facility failed to report a resident's aggressive and threatening behavior, including an assault on a nurse, to the State Survey Agency within the required five-day period. The resident exhibited violent behavior, resulting in the nurse's injury and the resident's arrest, but the incidents were not reported as required.
The facility failed to revise the care plan for a resident to include a prescribed dysphagia advanced diet and did not include required interdisciplinary team members in care plan meetings for another resident. This could result in staff being unaware of changes in care and residents not receiving appropriate care.
The facility failed to provide necessary mental health services for a resident with dementia, depression, and anxiety, despite physician's orders. The resident exhibited aggressive behaviors, and staff interventions were limited to redirection. Interviews revealed a lack of awareness and documentation regarding the resident's mental health needs and the absence of available psychiatric services.
A facility failed to provide timely social services for a resident who requested to be transferred closer to his wife. Despite multiple requests and family agreement, the first documented referral was made months later, and the facility's Social Service Director could not specify other facilities contacted. The resident's medical record lacked documentation of other referral attempts.
A resident was prescribed Risperidone without a documented psychiatric diagnosis to justify its use. The DON confirmed that the psychiatric evaluation did not document a diagnosis of psychosis, and the resident's medical record lacked the necessary documentation to support the administration of the antipsychotic medication.
A facility failed to provide a complete discharge summary for a resident, missing critical information such as dietary recommendations, skin condition, infections, hearing and vision abilities, dental concerns, speech pattern, continence, assistance levels, signs of condition changes, therapy services, medication reconciliation, and education provided. The form was also not signed off by staff. The DON confirmed these deficiencies and the expectations for staff.
The facility failed to ensure staff received appropriate behavioral health training, resulting in inadequate care for a resident with significant behavioral health concerns. The resident exhibited aggressive behaviors, including threats and physical assault, but staff were not trained to manage these issues effectively.
A resident with a physician's order for a dysphagia advanced texture diet was served whole chicken nuggets and French fries instead of the required bite-sized, moist foods. This discrepancy was confirmed by both a CNA and the DON.
The facility failed to keep treatment carts locked when not supervised by staff, affecting all 61 residents on the 100 and 200 Units. Observations revealed unlocked and open treatment carts containing hydrocortisone lotions, scissors, and lancets, with no staff present. This was confirmed by an LPN, the Unit Manager, and the Administrator.
Improper Labeling and Storage of Food Items in Kitchen and Pantry
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices affecting all 64 residents who receive meals from the kitchen, when observations showed multiple food items in the walk-in refrigerator, freezer, and pantry were not stored under sanitary conditions. In the walk-in refrigerator, surveyors observed two butter blocks without dates, a large uncovered container of Jello with no date, chorizo dated 12/20/25, pears in a container with no date, a peanut butter bar dessert in a container with no date, and sliced ham in an open ziplock bag dated 01/01/25. In the pantry storage area, baked crispy pineapple cake was found with no date. In the walk-in freezer, surveyors observed opened Salsbury steak, chicken patties, lemon meringue pie, and pie crusts all without dates, and corn tortillas that were loosely opened, not tightly sealed, and dated 12/11/25. During an interview, the Dietary Manager stated that she checks food dates daily and that staff who unload the food truck are supposed to date boxes before storing them and date food when it is opened. She confirmed that there were items in the refrigerator and freezer with no dates, no covers on some food containers, food that was not tightly sealed, and food with outdated dates, and stated that her expectation is that staff date and mark foods and discard them when outdated.
Failure to Update Care Plans With Current Orders and Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans to reflect current physician orders and resident conditions for multiple residents. One resident had a physician’s order dated 12/31/25 for enteral feeding with 250 ml of Jevity 1.2 to be given when oral intake was less than 25% of meals, but the comprehensive care plan dated 04/22/25 did not include this enteral feeding order or related interventions. The DON confirmed that the resident’s enteral feeds and interventions were not documented in the care plan. Another resident, admitted on an unspecified date, was observed on 01/06/26 to have thick, layered toenails. This resident had a physician’s order dated 11/14/25 to check fingernails and toenails, trim and file as allowed every Tuesday and Friday, and document refusals. However, the care plan dated 12/28/25 did not include the nail care order or describe how staff manage care when the resident refuses nail care and becomes combative. A CNA reported that this resident does not allow staff to file or trim her nails and becomes combative, and the Unit Manager stated his expectation that the resident should be care planned for nail care and behaviors. A third resident had a physician’s order dated 12/29/25 for PRN oxygen therapy at 1–2 L/min via nasal cannula for low oxygen, but the care plan dated 09/08/25 did not include oxygen therapy or related interventions. The Administrator confirmed that the resident’s oxygen and interventions were not documented on the care plan and stated that oxygen should be documented there. Across these residents, surveyors identified that the facility did not ensure care plans were revised with the most current information, including new physician orders and behavioral responses to care, despite observations, record reviews, and staff interviews confirming the omissions.
Failure to Complete Required Performance Evaluations for CNAs
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to complete required performance reviews for certified nurse aides (CNAs). Record review of employee files showed that CNA #16, hired on 11/18/24, had no performance evaluations documented in the file. Similarly, CNA #17, hired on 09/20/24, also had no performance evaluations documented. During an interview on 01/13/26 at 9:27 AM, the administrator confirmed that there were no performance evaluations for CNA #16 and CNA #17 and acknowledged that performance evaluations were expected to be completed at least annually for CNAs. The report states that this deficient practice could likely result in staff being undertrained and providing inadequate care.
Lack of Physician Documentation of Benefit/Risk Analysis for Psychotropic and Antidepressant Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultant pharmacist recommendations regarding psychotropic and other medications were reviewed and acted upon by the prescribing physicians, including documentation of a resident-specific benefit/risk analysis or rationale when recommendations were not followed. For multiple residents receiving atypical antipsychotics or antidepressants, the pharmacy recommendation summary reports documented concerns and specific recommendations, but the medical records did not contain corresponding physician documentation explaining the clinical reasoning for continuing the medications or declining gradual dose reduction (GDR). The facility’s policies required a licensed pharmacist to perform monthly drug regimen reviews and for irregularities to be addressed, but the surveyors found that this process was not completed as required at the physician documentation level. For one resident with vascular dementia, unspecified dementia, anxiety disorder, and insomnia, the physician had ordered quetiapine 200 mg at bedtime for dementia with psychotic disturbance. The pharmacy recommendation summary noted that the resident was receiving quetiapine for dementia-related psychosis and included information that patients with dementia-related psychosis treated with atypical antipsychotics have an increased risk of death and cerebrovascular adverse events compared to placebo. The pharmacist’s review stated that a benefit/risk analysis warranted continuation at the present dose, but the physician did not provide a benefit/risk analysis with patient-specific information in the medical record explaining why the resident needed to remain on the medication. For another resident with Alzheimer’s disease and dementia with behavioral disturbance, the physician had ordered quetiapine 25 mg twice daily for dementia with psychotic disturbance. The pharmacy recommendation summary similarly documented that the resident was receiving quetiapine for dementia-related psychosis and reiterated the increased risk of death and cerebrovascular adverse events associated with atypical antipsychotics in this population. The pharmacist again concluded that a benefit/risk analysis supported continuation at the current dose, yet the physician did not document a resident-specific benefit/risk analysis in the chart to justify ongoing use. A third resident with dementia and agitation had a physician’s order for Rexulti 1.5 mg once daily, later documented in the pharmacy recommendation summary as Rexulti 2 mg once daily in the evening for dementia with behavioral disturbance and agitation. The pharmacy report included the same warning about increased mortality and cerebrovascular events in elderly patients with dementia-related psychosis treated with atypical antipsychotics and stated that a benefit/risk analysis supported continuation at the present dose. However, the physician did not document a benefit/risk analysis with patient-specific information in the resident’s medical record. During an interview, the DON acknowledged that she did not see documentation in the charts specifically addressing benefit/risk analysis for these medications and stated that her expectation was that the physician would document this analysis. For a fourth resident diagnosed with depression, unspecified dementia without behavioral or psychotic disturbance, and anxiety disorder, the physician had ordered escitalopram 15 mg daily for depression and Zyprexa 5 mg daily at bedtime for dementia with psychotic disturbances. A pharmacy recommendation summary noted that the resident was receiving Zyprexa for dementia with psychotic disturbance and recommended consideration of GDR, again citing the increased risk of death and cerebrovascular adverse events in elderly patients with dementia-related psychosis treated with atypical antipsychotics. The pharmacist’s review stated that a benefit/risk analysis warranted continuation at the present dose, but the physician did not provide a resident-specific benefit/risk analysis in the record. A later pharmacy recommendation summary for the same resident indicated that escitalopram 15 mg daily was being given and recommended consideration of GDR; the physician did not provide a rationale with patient-specific information as to why a GDR was not done. In an interview, the DON confirmed that a rationale and benefit/risk analysis were not documented in this resident’s medical record and reiterated that her expectation was that such documentation should be present.
Inaccurate Dental, Activity, and Skin Documentation in Resident Records
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for multiple residents. One resident’s admission assessment, dated 11/17/25, documented that the resident had no natural teeth or tooth fragments and was edentulous, while direct observation and interview showed the resident had several broken, discolored teeth that needed to be pulled. An LPN and the DON later confirmed that the resident was not edentulous and that the admission assessment was inaccurate, despite the expectation that staff accurately assess and document dental status. Additional documentation inaccuracies were identified in activity and skin records. For one resident, a family member reported the resident wanted to attend Christian church services and was told Catholic services were available, but the activities participation records from October to December 2025 contained no documentation of church attendance, even though the unit manager and activities director stated the resident was taken off the secure unit for church. Another resident’s care plan called for encouragement to participate in activities and provision of one-to-one programs as needed, yet the activities participation records for the same period showed no one-to-one activities documented, despite the unit manager stating these occurred at least daily. A further resident was observed with a bleeding right elbow wound that was bandaged by an LPN, and later with a dressing that was falling off and appeared unchanged since the injury; however, a skin assessment dated 01/08/26 documented no skin issues. The wound care nurse and DON confirmed the presence of the wound and that the skin assessment was inaccurate, despite expectations for at least weekly, accurate skin assessments.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the resident’s call light was within reach. During an observation of the resident’s room, the surveyor noted that the resident’s call light was hanging over the light fixture above the bed, approximately six feet from the floor, making it inaccessible to the resident. In an interview, CNA #8 confirmed that the call light was hanging from the light fixture and that the resident could not reach it. In a separate interview, the Administrator acknowledged that residents should be able to reach their call lights. These observations and interviews show that the facility did not ensure the resident’s call light was positioned so the resident could use it, resulting in a failure to provide reasonable accommodation for the resident’s need to summon assistance.
Inaccurate MDS Assessments for Dental Status and Vascular Diagnoses
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, admission documentation showed she was admitted on an unspecified date, and during observation and interview she reported having several broken teeth that needed to be pulled. The surveyor observed broken teeth and discoloration of the upper and lower mouth. However, the resident’s admission MDS assessment documented that she was edentulous (lacking teeth). An LPN later observed the resident and confirmed she was not edentulous, and the DON acknowledged that the admission MDS inaccurately documented the resident as edentulous and that staff were expected to ensure MDS assessments were accurate. For another resident with a diagnosis of unspecified cerebral infarction, medical record review showed a CTA of the neck revealed complete occlusion of the right common carotid artery and greater than 70% stenosis of the left proximal internal carotid artery, with a recommendation for neurovascular evaluation. A provider progress note documented diagnoses of stenosis of the left internal carotid artery and occlusion of the right internal carotid artery, and that these serious findings and associated risks were discussed with the resident. Despite these documented diagnoses, the resident’s subsequent Quarterly MDS assessment did not include the CTA-related diagnoses in Section I (active diagnoses). The MDS coordinator stated she was unaware of these diagnoses, explained that the medical team liaison usually notifies her of new diagnoses, and acknowledged that the CTA findings should have been added to the resident’s MDS.
Failure to Update Enteral Feeding Order to Reflect Current Practice
Penalty
Summary
The facility failed to meet professional standards of practice by not updating a physician’s order for a resident’s enteral feeding regimen. Record review showed an active order dated 11/08/25 for Jevity 1.2 via PEG tube four times a day, and a subsequent order dated 12/01/25 for a regular/liberalized pureed diet with nectar-thick liquids, allowing sandwiches and soft snacks with supervision. During interview, one LPN stated that the resident only receives Jevity through the PEG tube when oral intake is less than 50% of meals, while another LPN reported that the resident no longer receives PEG tube feedings and is eating 100% of meals by mouth and has been doing so for a long time. The nurse practitioner confirmed that the resident is currently eating by mouth and acknowledged that the existing order for PEG tube feeding four times a day had not been updated to reflect the current practice of administering PEG feeding only if the resident consumes less than 50% of the meal orally. The DON also confirmed that the order had not been updated and stated that it should specify that PEG feeding is to be used only when the resident eats less than half of the meal by mouth. This discrepancy between the written physician’s order and the care actually being provided led to the deficiency related to professional standards of quality.
Failure to Assess, Document, and Treat a New Elbow Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate treatment and care for a resident’s right elbow wound. The resident was admitted on an unspecified date, and on 01/05/26 was observed near the nurses’ station with blood on the right elbow. An LPN cleansed the elbow and applied a bandage, stating the resident had scraped the elbow on the wheel of his wheelchair. However, there was no documentation in the medical record that the resident had a wound on the right elbow, that a dressing had been placed, or that any wound assessment had been completed. On 01/08/26, the resident was observed in the hallway with a dressing that was falling off the right elbow and appeared to have dried blood. The resident stated staff had not changed the bandage since the wound occurred on 01/05/26. The wound care nurse reported she was not aware the resident had a right elbow wound until that observation and confirmed the presence of the wound and deteriorating dressing. She stated that when a new wound is identified, staff are expected to assess the wound, notify the provider and family, document the wound and notifications in the medical record, and enter wound care orders. She confirmed there was no documentation of the wound, no evidence the provider was notified, and no wound care orders in the record. The DON similarly confirmed that staff are expected to evaluate and clean new wounds, notify the provider and family, and enter wound care orders, and acknowledged that staff did not document the wound, notify the provider or family, or enter any wound care orders for this resident’s right elbow wound.
Failure to Follow Oxygen Orders and Document Respiratory Status Change
Penalty
Summary
The deficiency involves staff failing to follow a physician’s order for oxygen therapy and failing to document a change in respiratory care for one resident. The resident had chronic respiratory failure with hypoxia, COPD, and a tracheostomy, and had a physician’s order for an oxygen concentrator set at 3 LPM on all shifts. During observation, the resident’s oxygen concentrator was found set at 4 LPM, and the resident reported that staff had increased the flow from 3 LPM to 4 LPM a couple of days earlier when his oxygen saturation was 72%. A subsequent observation again confirmed the concentrator remained at 4 LPM. Record review showed no documentation of when the oxygen flow was increased, no respiratory assessment to support the change, and no evidence that the provider was notified or that new orders were obtained. An LPN confirmed the discrepancy between the ordered 3 LPM and the observed 4 LPM setting and acknowledged there was no documentation explaining the change or provider notification. The DON stated that staff were expected to document an assessment, notify the provider and family, and obtain new orders when a resident’s respiratory status changed and oxygen concentration was adjusted, but confirmed that none of this was documented for this resident, and there were no messages in the communication application regarding a change in respiratory status or the need to increase oxygen concentration.
Failure to Ensure Routine Dental Services for a Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental services, including an annual inspection of the mouth and necessary dental care such as cleaning, fillings, or denture adjustments, as required. The resident was admitted on 04/10/25, and record review and interviews confirmed that no dental visit had occurred since admission. During an interview, the resident’s family member stated that the resident had not seen a dentist while at the facility and noted that the resident had missing teeth. In a separate interview, the resident reported that she had not been to the dentist and expressed a desire to go. Social Services confirmed that the resident had not been seen by a dentist since admission. This deficient practice was identified as likely to cause the resident unnecessary pain, embarrassment over the condition and appearance of her teeth, and potential dental or oral complications. The deficiency centers on the facility’s inaction in arranging or providing access to dental services for the resident after admission, despite the resident’s missing teeth and expressed wish to see a dentist, and confirmation from Social Services that no dental visit had been facilitated during her stay.
Failure to Provide Required Annual In‑Service Training for CNAs
Penalty
Summary
The facility failed to ensure that CNAs received the required 12 hours of annual in‑service training, including dementia care and abuse prevention, as identified through record review and staff interview. Review of employee files showed that one CNA hired on 11/18/24 and another CNA hired on 09/20/24 had no documentation of any in‑service trainings in their personnel files. During an interview on 01/13/26 at 9:27 AM, the administrator confirmed that there was no documentation of in‑service trainings for these two CNAs and acknowledged that CNAs were expected to complete at least 12 hours of in‑service training annually. This lack of documented training was cited as a deficiency because it was likely to result in CNAs not receiving the necessary training to meet residents’ care needs. No specific residents, medical histories, or clinical conditions were mentioned in the report in connection with this deficiency.
Failure to Follow Transmission-Based Precautions for COVID-19
Penalty
Summary
Staff failed to maintain proper infection prevention and control measures for a resident diagnosed with COVID-19. During an observation, a yellow disposable isolation gown was found hanging on a hallway rail outside the resident's room, which was under droplet/COVID precautions. The posted sign indicated that staff should wear an N95 mask, gown, and face shield or goggles to enter the room. According to interviews, the expectation was that personal protective equipment (PPE), including gowns, should be disposed of after use and not left exposed in the hallway. An LPN confirmed that the gown should have been discarded in a bin after use, and the DON stated that all PPE must be worn inside the resident's room and removed before exiting to the main hall. The resident had been isolated to their room for 14 days following a positive COVID-19 diagnosis upon return from the hospital. The failure to properly dispose of the isolation gown and adhere to transmission-based precautions constituted a breach in the facility's infection control program.
Failure to Maintain Safe Operating Condition of Kitchen Griddle
Penalty
Summary
The facility failed to ensure that essential kitchen equipment, specifically the griddle, was maintained in safe operating condition. During an observation of the kitchen, it was noted that all four knobs on the gas griddle were missing, making it impossible to properly control the gas burners. This deficiency affected 69 out of 72 residents who consumed food prepared in the kitchen, as identified by the resident matrix provided by the Administrator. The absence of the knobs was confirmed by the Dietary Manager during an interview.
Failure to Safeguard Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information for three residents. In one instance, the privacy curtain between two residents' beds was observed to be off track, leaving a gap at the top and preventing it from being fully closed. Both a nurse aide and an LPN confirmed that the curtain had been in this condition for several months, compromising the residents' ability to have private space during care or personal activities. Additionally, a paper towel containing a resident's name and vital signs was found left unattended on a wheelchair in the hallway outside the resident's room, with no staff present. An LPN acknowledged that this information should not have been exposed in a public area, and the Director of Nursing confirmed that resident information should not be written on a paper towel and that a protected vital sheet is the appropriate method for recording such data.
Failure to Update Care Plans with Current Resident Information and Medication Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information for two residents. For one resident, documentation showed that the resident expressed a desire to be discharged to an assisted living facility, and this was discussed with the guardian and during a care plan meeting. However, the resident's care plan continued to state that discharge was not expected and did not reflect the updated discharge plan or the resident's expressed wishes. For another resident, physician orders were in place for two psychotropic medications, trazodone and mirtazapine, prescribed for circadian rhythm disorder and depression, respectively. Despite these orders, the resident's care plan did not include any interventions or goals related to the use of these medications. The DON confirmed that the care plan lacked the required information for these medications and acknowledged that interventions and goals should have been included.
Failure to Provide Foot Care for Diabetic Resident
Penalty
Summary
Staff failed to provide appropriate foot care for a resident with type 2 diabetes mellitus. The resident was admitted with this diagnosis and, during observation, was found to have overgrown toenails and callused feet. The resident reported that staff had not offered to cut her toenails and that she had not seen a podiatrist since admission. Additionally, the resident stated she had lost a toenail, which was documented in a progress note, and was instructed to cleanse and dress the area until healed. Interviews with facility staff confirmed that the resident's toenails were long and had not been cut. Staff also acknowledged that the facility did not have a podiatrist available to provide foot care, and no referrals had been made for the resident to see a podiatrist until recently. Nursing staff indicated that residents' nails should be checked weekly, but this had not occurred for the resident in question.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
Staff failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses of hypertension and paroxysmal atrial fibrillation, physician orders required blood pressure and heart rate monitoring prior to administering medications such as metoprolol, lisinopril, and furosemide. However, staff did not document the required blood pressure or heart rate readings on the medication administration record (MAR) or in the vital signs section of the medical record on multiple occasions throughout August. The Director of Nursing confirmed that staff are expected to document these vital signs as indicated in the physician's orders, either on the MAR or in the vital signs section. For another resident admitted with a diagnosis of circadian rhythm sleep disorder, the MAR incorrectly listed the indication for mirtazapine as depression, while the psychiatric provider's note and the Director of Nursing confirmed the medication was prescribed for circadian rhythm disorder. The DON acknowledged that staff entered the order with the wrong indication. These documentation errors resulted in incomplete and inaccurate medical records for both residents.
Failure to Assist with Personal Hygiene—Fingernail Care
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required partial to moderate help with personal hygiene. Record review showed the resident was admitted to the facility and required assistance, as documented in the most recent MDS assessment. During an observation, the resident's fingernails were found to be overgrown, jagged, and uneven from breaking off. The resident reported that staff had not offered to cut her fingernails and that she did not have clippers to do it herself. A CNA confirmed that the resident's fingernails were long and had not been cut.
Failure to Investigate Abuse Allegation Involving Deceased Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse/mistreatment involving a deceased resident. The incident involved a staff member, RN #1, who used the deceased resident to play a prank on another staff member, NA #1. RN #1 instructed NA #1 to take the vital signs of the deceased resident, which was intended as a joke. This action was not identified as abuse or mistreatment by the facility, and the incident was not reported to the state as required. The facility did not conduct a thorough investigation into the incident. The Administrator, who is the abuse coordinator, was not aware of the prank aspect of the incident until receiving an email from NA #1's family member. The investigation was initially focused on improper postmortem care rather than the mistreatment of the resident. RN #1 was not immediately removed from duty, and there was no documentation of reprimand for disrespecting the deceased resident. Additionally, there was no education provided to staff regarding the respect and dignity of deceased residents. The facility's failure to recognize and address the incident as abuse/mistreatment resulted in an Immediate Jeopardy situation. The facility's Abuse Prohibition Policy requires immediate reporting and removal of staff involved in alleged abuse, which was not followed in this case. The lack of immediate corrective action and staff education put residents at risk of similar mistreatment.
Failure to Recognize Mistreatment of Deceased Resident
Penalty
Summary
The facility failed to maintain the highest practicable well-being of a resident, identified as R #16, when the administration did not recognize the mistreatment and disrespect shown to the resident after her death. The incident involved RN #1 instructing NA #1 to take the vital signs of R #16, who had already passed away, as part of a prank on another staff member. NA #1, upon discovering the resident was deceased, was distraught and required emergency medical services due to a panic attack. The administration did not initially recognize the incident as mistreatment, and it was not reported to the state as a staff-to-resident incident. The Administrator, who is also the Abuse Coordinator, led the investigation but did not acknowledge the prank as inappropriate or recognize the mistreatment of the deceased resident. The Administrator believed the incident was a staff issue and did not report it to the state. It was only after receiving an email from NA #1's family member that the Administrator initiated an investigation. The investigation revealed that RN #1 had used the situation as a teaching opportunity, and no corrective action or education was provided to RN #1 or other staff regarding the respect of deceased residents. The facility's investigation report lacked documentation of the Director of Nursing's involvement or oversight of RN #1 and other nursing staff involved. RN #1 received a written reprimand for sending NA #1 to take vitals on a deceased resident, but there was no reprimand related to the mistreatment of the deceased resident. The facility's failure to recognize and address the mistreatment of a deceased resident resulted in an Immediate Jeopardy situation, which was later addressed through a plan of removal.
Disrespectful Prank Involving Deceased Resident
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and respect when a staff member used the deceased resident to play a prank on another staff member. The incident involved a resident who was admitted to the facility and had a full code status, indicating they wished to receive all possible life-saving measures. After the resident passed away, a nurse instructed a nursing assistant to take the deceased resident's vital signs as part of a prank, without the consent of the resident or their family. This action was disrespectful and dehumanizing to the deceased resident and their family. Multiple staff members, including nursing assistants and the unit manager, were aware of the prank, and some did not attempt to prevent it. The administrator was informed of the incident and initially believed it was intended as a teaching opportunity rather than a joke. However, a family member of the nursing assistant later clarified that it was indeed a prank. The deceased resident's son expressed that his mother would have been horrified by the incident, describing it as disgusting. The nurse involved in the prank did not respond to attempts to contact them for an interview.
Failure to Provide Timely Transfer Notices
Penalty
Summary
The facility failed to provide timely written notices of transfer to residents, their representatives, and the Ombudsman for four residents who were hospitalized. Resident #8 was transferred to the hospital twice, once for a fall and once for evaluation of an abdominal wound and fever, but no written transfer notices were documented. Resident #9 was sent to the hospital due to abnormal lab results, and Resident #11 was hospitalized following a fall, both without written transfer notices. Similarly, Resident #13 was sent to the hospital for altered mental status, and no written transfer notice was recorded. During an interview, the Director of Nursing confirmed the absence of transfer notices for these residents, acknowledging that such notices should be completed at the time of transfer or as soon as practicable.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written notices of the bed hold policy to residents or their representatives, which specifies the duration the bed would be held during hospital transfers or therapeutic leave. This deficiency was identified for four residents who were transferred to the hospital for various medical reasons, including falls, evaluation of an abdominal wound and fever, abnormal lab results, and a change in mental status. Upon review of the medical records for these residents, it was found that none contained the required written notice of the bed hold policy. During an interview, the Director of Nursing (DON) confirmed the absence of these notices and was unable to recall when the bed hold should be provided to the residents.
Failure to Update Care Plans for Resident Refusals
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, leading to deficiencies in the care provided. Resident #1, who was admitted with a need for assistance with personal care, had a history of refusing showers. However, the care plan did not include any interventions to assist or encourage the resident when she refused to shower. Similarly, Resident #14, diagnosed with type 2 diabetes mellitus, refused blood glucose checks and insulin, believing she was cured. The care plan for this resident did not document her noncompliance or include interventions for her refusals, despite the Director of Nursing being aware of the situation. Resident #17, also admitted with a need for assistance with personal care, was noted to refuse having his teeth brushed at times. The care plan for this resident lacked documentation of his refusals and did not outline any interventions to assist or encourage him. The Director of Nursing confirmed that the refusals were not documented and that interventions should have been included in the care plan. These oversights in updating care plans with current resident information could result in staff being unaware of changes in care needs and residents not receiving appropriate care.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, specifically in the areas of oral care and bathing. Resident #1, who required substantial assistance for showers, was not consistently offered or given showers according to the facility's schedule. Documentation showed that Resident #1 received only four out of nine scheduled showers in December and four out of six in January. Additionally, there was no documentation explaining why showers were missed on specific days. Resident #1's family member confirmed that the resident was not showered on scheduled days, and a CNA noted that if Resident #1 refused a shower, it was not offered again until the next scheduled day unless requested by the resident. Resident #2, who was dependent on staff for showers, was also not consistently provided with scheduled showers, receiving only three out of nine in December and four out of six in January. The CNA confirmed that Resident #2 was cooperative and did not refuse showers, yet no explanation was provided for the missed showers. Resident #17, also dependent on staff for showers, received only one out of nine scheduled showers in December and two out of six in January. The DON confirmed the lack of documentation for missed showers and noted that Resident #17 should receive two showers per week. Additionally, Resident #17's oral care was neglected, with teeth brushed only a few times during the day shift, despite the expectation of twice-daily brushing. The DON acknowledged the inconsistency in oral care documentation, particularly during the day shift.
Failure to Follow Physician Orders for Weighing and Insulin Administration
Penalty
Summary
The facility failed to ensure that staff followed physician's orders for two residents, leading to potential risks in their care. For one resident, the facility did not adhere to the physician's order to weigh the resident weekly, as evidenced by the weight log showing missed weigh-ins over several months. This resident, who was underweight and had a low BMI, was only weighed sporadically, which could have hindered the monitoring of their nutritional status and overall health. For another resident, the facility did not follow the physician's orders regarding insulin administration. The resident's medical records showed multiple instances where blood glucose levels were not documented, and insulin was not administered as prescribed. Additionally, there was no documentation that the physician was notified when insulin was held or when the resident was noncompliant with blood glucose checks and insulin administration. This lack of communication and documentation could have led to unawareness of changes in the resident's condition.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its own policies regarding food handling, staff attire, and hand hygiene, which had the potential to affect 56 residents consuming food prepared by the facility's kitchen. During an initial tour of the kitchen, it was observed that a gallon jug of milk was open without an open date, contrary to the facility's policy that requires dating of food items once opened. Additionally, several spices were found on the shelf without open dates, indicating a lapse in following the established food handling procedures. Staff attire and hygiene practices were also found to be lacking. Dietary staff were observed not wearing beard covers or hair nets as required by the facility's policy. One staff member was seen making burritos without a beard cover, and another walked through the kitchen without a hair net while carrying personal belongings. The Dietary Manager was observed with a beard cover under his chin, not properly covering his facial hair, which was acknowledged as inappropriate by the staff during interviews. Hand hygiene practices were not consistently followed, as observed during multiple instances where staff failed to wash hands between glove changes or after touching potentially contaminated surfaces. Staff were seen performing various tasks with the same pair of gloves, such as handling food, touching trash can lids, and retrieving items from different areas, without changing gloves or washing hands in between. The Dietary Manager and other staff demonstrated incorrect handwashing techniques, such as turning off faucets with elbows and touching trash can lids, which contradicted the facility's handwashing policy that requires using a paper towel to turn off the faucet and ensuring hands are not recontaminated.
Failure to Complete Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment was successfully transmitted and accepted within the required time frame. According to the October 2023 Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous assessment. However, the quarterly MDS assessment for a resident with medical diagnoses including hypertension and diabetes type II, with an Assessment Reference Date (ARD) of 07/23/24, was not completed. The MDS Coordinator confirmed that the assessment was past due by more than 120 days, indicating a lapse in the facility's adherence to the automatic scheduling system on the Point Click Care System.
Failure to Complete and Transmit Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment for a resident was successfully transmitted and accepted within the required timeframe. According to the Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous assessment. However, the quarterly MDS assessment for a resident, who was admitted with medical diagnoses including hypertension and diabetes type II, was not completed within this timeframe. The resident's annual MDS assessment with an Assessment Reference Date (ARD) of January 21, 2024, was accepted, as was the quarterly MDS with an ARD of April 22, 2024. However, the subsequent quarterly MDS assessment, which should have had an ARD of July 23, 2024, was not completed, resulting in a delay of 120 days past the due date. During an interview, the MDS Coordinator confirmed that the MDS assessments are scheduled automatically in the Point Click Care System. The coordinator acknowledged that the quarterly assessment for the resident was not completed as required, confirming the deficiency. This oversight indicates a failure in the facility's process to ensure timely completion and transmission of MDS assessments, as mandated by the RAI Manual guidelines.
Failure to Update PASARR After New Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed after a new diagnosis for a resident. The resident was admitted and re-admitted with diagnoses of anxiety, bipolar disorder, and major depressive disorder. The PASARR Level 1 Screening Form included the diagnosis of anxiety but did not reflect the new diagnoses of bipolar disorder and major depressive disorder. During an interview, the Admissions Coordinator stated she was unaware of the changes in the resident's diagnosis and relied on the Director of Nurses to inform her if a PASARR needed to be completed. The New Mexico PASARR personnel confirmed that a re-screening should have been conducted following the addition of the new diagnoses.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced multiple falls, which was identified during a review of records, interviews, and policy reviews. The resident, who had diagnoses including dementia, weakness, and unsteadiness on feet, was admitted to the facility and had a history of falls. Despite these incidents, the care plan was not updated with new interventions to prevent future falls. The resident's quarterly Minimum Data Set (MDS) assessments indicated a decline in cognitive function and recorded falls, yet the care plan remained unchanged since August 2022. The facility's incident reports and progress notes documented several falls, including an unwitnessed fall from a wheelchair and a fall while walking, but no preventative interventions were added to the care plan. Interviews with the Director of Nursing confirmed that the care plan had not been updated with new interventions after each fall. The facility's policies on falls management and accidents/incidents required the implementation of interventions to reduce risk and minimize injury, as well as adjustments to individualized intervention strategies as patient conditions change. However, these policies were not followed, as evidenced by the lack of updates to the resident's care plan despite multiple falls and changes in the resident's condition.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain clean oxygen concentrator filters for two residents, leading to a potential risk of infection and unnecessary respiratory treatment. Resident 29, diagnosed with heart failure, was observed to have a heavily debris-laden and dirty oxygen filter on their concentrator during multiple observations. The facility's policy required weekly cleaning of these filters, but this was not adhered to, as confirmed by the Unit Manager and the Director of Nursing during an interview. They acknowledged the filter's condition was unacceptable and identified a lack of clarity regarding the responsibility for cleaning the filters, with conflicting statements about whether it was the duty of certified nursing aides or nurses. Similarly, Resident 43, who had diagnoses of chronic obstructive pulmonary disease and shortness of breath, was also found to have dirty oxygen concentrator filters during observations. The Director of Nursing confirmed that the filters needed cleaning, indicating a failure to follow the facility's policy for maintaining respiratory equipment. This oversight in maintaining clean equipment for both residents highlights a deficiency in the facility's adherence to its own policies, potentially compromising the residents' respiratory health.
Failure to Indicate Daily Census on Nurse Staffing Form
Penalty
Summary
The facility failed to indicate the daily census on the GenSTAR Daily Nurse Staffing Form, which is posted daily in a conspicuous area. This omission was observed on multiple occasions, specifically on 09/17/24 and 09/18/24, where the form lacked the required resident census information. The absence of this information could lead to uncertainty for resident family, friends, or other visitors regarding the ratio of nursing staff to residents. During an interview on 09/19/24, the Administrator confirmed that the daily census should have been filled in on the form to inform visitors about the staff-to-resident ratio.
Incomplete Medical Records for Resident's Meal Intake
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one of the residents reviewed for abuse. Specifically, the facility did not document the meal intake for a resident over several days, despite a CNA stating that the resident had not eaten breakfast or lunch for a week. The CNA reported that she had documented the resident's lack of eating, but the records did not reflect this information. Upon review, it was found that there were multiple instances where staff did not document the amount of meal intake for the resident on various dates and times. Additionally, the resident's medical record lacked any documentation indicating that the resident was not eating. The Director of Nursing confirmed that the CNA did not document the resident's lack of eating, which should have been recorded.
Sanitary Food Handling and Storage Deficiency
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 77 residents. During an observation of the kitchen, six frozen hamburger patties were found sitting on top of a microwave without being in a wrapper, on a plate, or in a container. Additionally, the Dietary Manager (DM) was observed not wearing a facial hair covering for his moustache and not wearing a hairnet. The DM confirmed that the hamburger patties should not be left out without proper containment and acknowledged that hair should be covered in the kitchen.
Failure to Report Resident Abuse and Assault to State Agency
Penalty
Summary
The facility failed to report an incident of abuse to the State Survey Agency within the required five-day period. The incident involved a resident who exhibited aggressive and threatening behavior towards staff and other residents. The resident made violent threats, threw objects, and ultimately assaulted a nurse, resulting in visible injuries and the resident's arrest. Despite these serious events, the facility did not report the incidents to the State Agency, as the corporate quality clinical nurse deemed it unnecessary since the assault was on a staff member. The Director of Nursing and the Administrator confirmed that no reports were made to the State Agency regarding the resident's threats, aggressive actions, or the assault on the nurse. The resident in question had a history of aggressive behavior, including making threats to staff and other residents, throwing objects, and attempting to obtain cigarettes with sticks. The resident's actions escalated to physical violence when they threw silverware at a nurse, causing reddened marks on her face and neck. The nurse called the police, who arrested the resident for battery against a medical professional. Despite the severity of the incidents, the facility did not document the duration of the one-to-one observation for the resident and failed to report the incidents to the State Agency, as required by regulations.
Failure to Revise Care Plans and Include Interdisciplinary Team Members
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to potential gaps in care. For one resident, the care plan did not include the prescribed dysphagia advanced diet, despite a speech therapy evaluation and a medical order indicating the need for a regular/liberalized diet with moist foods in bite-sized pieces. This omission was confirmed by the Director of Nursing (DON) during an interview. The resident's care plan was not updated to reflect the necessary dietary adjustments, which could result in staff being unaware of the resident's specific dietary needs. For another resident, the care plan meetings did not include the required interdisciplinary team members. The meetings were attended by the MDS coordinator, the Social Services Director (SSD), and the Activities Director, but did not include nurses, CNAs, or the resident's provider. The MDS coordinator confirmed that she schedules the meetings and gathers information from the MDS assessment, which only covers a 7-day look-back period and does not provide a comprehensive view of the resident's condition. This lack of comprehensive input could lead to incomplete care plans that do not fully address the resident's needs.
Failure to Provide Mental Health Services
Penalty
Summary
The facility failed to provide necessary mental health services for a resident with a diagnosis of dementia, depression, and anxiety. Despite the physician's orders for psychiatric evaluation and treatment through Medi-tele care, the resident did not receive any mental or behavioral health services. The resident exhibited aggressive behaviors, such as throwing objects at staff and other residents, attempting to leave the facility, and making threats. The staff's interventions were limited to redirecting the resident and removing overstimulating items, but no formal mental health services were provided. Interviews with the Director of Nursing (DON), Medical Director, and Administrator revealed a lack of awareness and documentation regarding the resident's mental health needs and the absence of available psychiatric services. The DON confirmed that Medi-tele care had stopped providing services the previous year, and there were no alternative behavioral health services available in the community. The Medical Director did not recall being notified about the resident's behaviors, and the Administrator did not take the resident's threats seriously. No referrals were made to behavioral health hospitals, and the facility did not have any behavioral health services in place.
Failure to Provide Timely Social Services for Resident Transfer Request
Penalty
Summary
The facility failed to provide timely social services for a resident who requested to be transferred to another long-term care facility closer to his wife. The resident expressed his desire to move multiple times, starting from June 5, 2023, but the facility did not act promptly. Despite the resident's repeated requests and the family's agreement to find another facility, the first documented referral was not made until January 17, 2024. The facility's Social Service Director (SSD) confirmed that only one referral packet was sent and could not specify any other facilities contacted for the transfer. The resident's medical record lacked documentation of any other referral attempts before January 17, 2024. The resident's progress notes indicated ongoing communication between the facility, the resident, and his family about the transfer. However, the facility's actions were delayed and insufficient. The SSD acknowledged the responsibility for making referrals but failed to provide timely and adequate referrals. The facility's documentation did not support that multiple facilities were contacted, and the only referral made was to a facility 148 miles away from the resident's desired location. This lack of timely action and proper documentation led to the deficiency in providing necessary social services to the resident.
Failure to Document Psychiatric Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic medications unless necessary to treat a specific psychiatric diagnosis documented in the medical record. Specifically, a resident was prescribed Risperidone, an antipsychotic medication, without a documented diagnosis of psychosis or any other psychiatric condition that would justify its use. The resident's medical record, including the care plan and physician's orders, did not contain any documentation of a psychiatric diagnosis to support the administration of Risperidone. The Director of Nursing (DON) confirmed that the resident was sent for a psychiatric evaluation, which led to the prescription of Risperidone, but the evaluation did not document a diagnosis of psychosis or any other psychiatric condition. The deficiency was identified through a review of the resident's admission record, physician's orders, and Medical Administration Record (MAR), as well as an interview with the DON. The DON acknowledged that the psychiatric evaluation did not provide a diagnosis to justify the use of Risperidone and confirmed that the resident's medical record lacked the necessary documentation. This oversight could result in the resident receiving unnecessary medication, increasing the risk of adverse side effects.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident at the time of a planned discharge. The discharge summary for the resident, who was discharged on a specified date, was missing critical information including dietary recommendations, skin condition, current infections, hearing and vision abilities, dental concerns, speech pattern, bowel and bladder continence, assistance levels, signs and symptoms of a change in condition, therapy services received, medication reconciliation, education provided, and other attachments. Additionally, the form was not signed off by staff. During an interview, the Director of Nursing (DON) confirmed that the discharge summary was incomplete and acknowledged that staff are expected to complete the entire discharge summary document prior to the resident being discharged. The DON also confirmed that staff are required to perform a medication reconciliation and provide a copy of the discharge summary and medication reconciliation to the resident, their representative, and/or the home health agency before the resident leaves the facility.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that staff received the appropriate behavioral health training and possessed the skills to provide behavioral health services for a resident with significant behavioral health concerns. The resident exhibited aggressive and disruptive behaviors, including attempting to break into an ashtray, stealing from other residents and staff, making threats of violence, and physically assaulting a nurse. Despite these behaviors, there was no documentation that the provider was notified about the resident's actions, and the resident did not receive any mental health services while in the facility. Interviews with staff revealed that they were not adequately trained to handle such aggressive behaviors. The RN involved in the incidents confirmed that she had not received any training related to behavioral health or dealing with aggressive residents. The Director of Nursing (DON) and the Social Services Director (SSD) also confirmed that while some CNAs had received training on managing aggressive behaviors, the rest of the facility's staff, including nurses and other clinical staff, had not received this training. The SSD provided an 8-hour training on managing aggressive behaviors to some CNAs, but this training was not extended to the entire staff. The lack of comprehensive training and skills competencies for dealing with behavioral health issues and aggressive behaviors contributed to the facility's inability to manage the resident's actions effectively, leading to a deficiency in providing the necessary care and assistance to meet the resident's behavioral health needs.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by a physician for one resident. The resident had a physician's order for a regular/liberalized diet with dysphagia advanced texture, which requires bite-sized, moist foods excluding crunchy, sticky, or very hard foods. However, during an observation, the resident was served whole chicken nuggets and whole French fries, which did not comply with the prescribed diet. This was confirmed by a CNA and the Director of Nursing (DON), who acknowledged that the resident should have been served mechanical soft, chopped bite-sized foods.
Unlocked Treatment Carts
Penalty
Summary
The facility failed to keep treatment carts locked when not supervised by staff, affecting all 61 residents on the 100 and 200 Units. On 05/06/24 at 2:30 PM, an observation of the 100 Unit revealed an unlocked and open treatment cart containing hydrocortisone lotions, scissors, and lancets, with no staff present. This was confirmed by an LPN. On 05/07/24 at 8:58 AM, a similar observation was made on the 200 Unit, with the treatment cart also unlocked and open, containing similar items, and no staff present. The Unit Manager confirmed this observation. The Administrator later confirmed that the expectation is for treatment carts to be locked when not in use.
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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