Taos Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Taos, New Mexico.
- Location
- 1340 Maestas Road, Taos, New Mexico 87571
- CMS Provider Number
- 325105
- Inspections on file
- 26
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Taos Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility failed to consistently track, resolve, and communicate outcomes of resident grievances. During a resident council meeting, a resident reported that grievances were submitted but never followed up on, citing unresolved issues such as poor communication with Spanish-speaking kitchen staff who were not following meal tickets, lack of dietary representation at council meetings, missed appointments possibly related to low transport staffing, unreturned laundry, and a longstanding lack of hot water. Another resident reported not receiving showers due to no hot water. A Regional Nurse Consultant later stated that the SSD or Administrator were responsible for grievance follow-up and that the SSD was the grievance official, with an expectation that all grievances be resolved within five working days, which contrasted with residents’ reports of no feedback or resolution.
The facility failed to maintain a safe, clean, and homelike environment by not ensuring consistent hot water access, proper environmental maintenance, and appropriate use of resident care areas. Multiple residents reported ongoing lack of hot water, especially at night, resulting in missed or cold showers and reliance on boiled water from the kitchen. Staff interviews confirmed persistent boiler and water system issues, and surveyors measured substandard hot water temperatures in several rooms and in the dishwashing machine, with incomplete temperature logs. The main dining room had missing and stained ceiling tiles, exposed wiring, unsecured cords near dining tables, and dusty vents above resident seating. Resident rooms and bathrooms showed broken blinds, slow-draining sinks, blood-like smears on walls, missing outlet covers, exposed light bulbs, dead insects in light fixtures, and showers used to store equipment and random items.
Surveyors found that the facility did not meet professional standards when one resident used and stored respiratory medical equipment brought in by family without any physician orders, despite leadership acknowledging staff should ensure orders exist for such devices. In addition, a resident at risk for PUs due to impaired mobility and fragile skin had a care plan requiring weekly skin assessments by licensed nursing staff, but documentation showed that no weekly skin checks were completed for three consecutive weeks, which was confirmed by the WCN and regional nursing leadership as not in accordance with expectations.
The facility did not complete required annual performance reviews for several CNAs who remained actively employed. Review of staffing and personnel records showed that multiple CNAs lacked documented annual evaluations, despite a requirement that each CNA undergo a yearly performance review. An RN responsible for CNA training and evaluations, as well as a regional nurse consultant, both confirmed that these CNAs did not have the required annual performance reviews completed.
Surveyors identified that the facility’s medication error rate exceeded 5% when three residents experienced errors during observed medication passes. One resident received a delayed-release divalproex tablet in crushed form without a specific medical order to crush it, and another resident’s extended-release phenytoin capsule was crushed and administered despite a package label stating “do not crush” and no documented medical need to do so. A third resident missed multiple ordered doses of Symbicort inhaler because the medication was not available on site and had not yet been delivered from the pharmacy, resulting in several consecutive missed administrations.
Surveyors found expired ReliOn Ultra Thin Lancets stored with blood glucose testing supplies in a medication storage room, indicating that expired single-use needles used for capillary blood sugar checks had not been removed from stock. An RN acknowledged the lancets were expired and reported being unaware of the policy on medical supply expiration dates, while the DON stated her expectation that expired products, including lancets, be discarded and that non-expired lancets may be used for care.
The facility failed to provide meals consistent with posted menus and documented food preferences for multiple residents. One resident with chronic respiratory failure on a heart healthy diet did not receive the salad requested on her meal ticket and was told by kitchen staff that no salad was available, despite expectations from the RD and Dietary Manager that it should have been prepared. Another resident with muscle wasting on a regular diet was served mashed potatoes instead of the potato salad listed on her ticket and reported that menu items were often inconsistent with what was actually served. The Regional Nurse Consultant confirmed that menus should have been updated and residents should have been served what was listed.
Surveyors found multiple failures in food storage and monitoring, including expired dressings, juices, and yogurt in refrigerators, exposed ground meat and opened wafers left uncovered, and broken eggshells stored with intact eggs. Required daily logs for dish machine PPM, refrigerators, and freezers were not current, with no recent entries. During observation, the Dietary Manager was unable to clearly identify safe food temperatures for items prepared for resident service and admitted falling behind on updating temperature logs, while the RD stated she expected the Dietary Manager to know safe temperatures and maintain up-to-date logs, with shared responsibility between them.
Two residents experienced lapses in infection prevention and control when one resident with COPD had spirometers and a nebulizer left on the bed and windowsill instead of being stored in labeled, dated bags to maintain cleanliness, and another resident received medication from an RN who picked up a glucosamine tablet that had fallen onto the top of the medication cart and placed it into a medication cup without gloves, despite facility expectations that such dropped pills be discarded and replaced.
The facility failed to maintain documentation showing that staff received education on the benefits and risks of the COVID-19 vaccine, were offered the vaccine or information on how to obtain it, and had their COVID-19 vaccination status recorded. During review of infection control records, surveyors were unable to locate staff vaccination lists, and the ADON/IP reported that she did not have a staff COVID-19 vaccination status list and does not provide COVID-19 vaccine education to staff.
The facility failed to obtain and document informed consent before administering psychotropic medications to three residents. Multiple anti-anxiety and other psychotropic drugs, including Buspirone, Clonidine, Lorazepam, Hydroxyzine, and Quetiapine, were ordered and given without signed psychotropic consent forms in the EHR. Pharmacist reviews for each resident noted that informed consent should be obtained at admission, prior to starting a psychotropic, or before dose increases, and that no consent forms were found. Psychotropic consent forms were later created and signed weeks to months after medication initiation, with consent dates documented as if obtained earlier. An LPN reported that the ADON was responsible for completing these consent forms prior to administration, and both the ADON and a regional nurse consultant acknowledged that consents were not completed before the medications were given.
A resident on approved leave was mistakenly believed to be missing, during which the DON sent text messages telling the resident to pick up belongings because of discharge, which the resident later described as confusing and threatening. When the resident returned, a night shift nurse entered the room, tapped or hit the resident’s foot, and used foul language, causing the resident to feel like a child and intimidated. The resident reported these concerns to an ADON, and multiple leaders, including the RNC and RA, acknowledged that the nurse’s foot-tapping and the DON’s text messages were inappropriate and were perceived by the resident as abusive or threatening.
A resident admitted with diagnoses of unspecified dementia with agitation and bipolar disorder had a PASRR Level 1 screening completed that incorrectly indicated no mental illness diagnosis. The Admissions Coordinator, who along with admissions liaisons was responsible for reviewing and ensuring accuracy of PASRR forms at admission, acknowledged that the PASRR did not reflect the resident’s bipolar disorder and that this inaccuracy was not identified or corrected during the admission review, resulting in a deficiency related to incomplete and inaccurate mental health assessment at admission.
A resident had a physician order for O2 at 2 LPM via nasal cannula and was reported by a CNA to wear O2 every day, but the comprehensive care plan did not include O2 use as an intervention. Review of the care plan and interviews with staff, including a Regional Nurse Consultant, confirmed that the resident’s O2 therapy was not added to the care plan despite the active order and ongoing use.
A resident with an order for PRN oxycontin 5 mg every four hours for severe pain only at a pain level of 8 or higher was repeatedly given the narcotic when documented pain scores were between 2 and 7. MAR review showed multiple administrations at these lower pain levels, contrary to the physician’s explicit parameters. An RN acknowledged she was not accustomed to orders specifying pain levels and confirmed that these administrations did not follow the physician’s orders, which was further confirmed by the regional nurse consultant.
A resident did not receive multiple scheduled doses of a prescribed Symbicort inhaler because the medication was not available on site and not stocked in the emergency medication system. An RN reported that the inhaler had been ordered from the pharmacy and was still pending delivery. Review of the MAR showed several consecutive missed doses, and the DON later confirmed that the facility’s process for addressing unavailable medications, including use of an emergency kit and timely pharmacy contact, was not followed.
The facility did not submit the required five-day follow-up report to the State Agency after investigating an allegation of abuse, neglect, or injury of unknown source involving a resident. This was confirmed by record review and interview with the Administrator.
A resident with multiple medical conditions and moderate cognitive impairment was allegedly handled roughly by a male staff member during care, leading to a family member reporting the incident as abuse. The administrator, after interviewing the resident and involved staff, concluded the event occurred elsewhere and did not conduct a thorough investigation, despite clarification from the family member that the incident happened at the facility.
The facility failed to maintain sanitary conditions in food storage and preparation, with undated and unlabeled food items, improper storage of eggs and cheese, and inadequate cleaning practices. Additionally, kitchen staff did not wear face masks appropriately during a respiratory virus outbreak, as observed by surveyors.
The facility failed to notify two residents and their families about room changes. One resident with severe cognitive impairment was moved without family notification, discovered by the family during a visit. Another resident was moved due to room painting, causing confusion and concern about her belongings. The DON and Administrator acknowledged the notification protocol but lacked documentation.
The facility failed to ensure that three residents had working portable oxygen concentrators, leading to inadequate oxygen levels. One resident's oxygen saturation was 82%, another appeared cyanotic and lethargic, and a third had a saturation of 89%. Staff were aware of the issue, but no corrective action was taken.
A resident with a history of Parkinsonism, dementia, and schizophrenia exhibited ongoing inappropriate behaviors towards female residents. Despite these behaviors, the facility failed to notify the resident's physician, as confirmed by interviews with the medical doctor and DON. The lack of communication was a deficiency in the facility's protocol.
A facility failed to investigate and document an incident where a resident kissed another resident in the dining room, witnessed by the latter's husband. The administrator relied solely on the husband's statement without verifying with other witnesses. The resident had a history of inappropriate behavior, but the facility did not document investigations into these incidents. The resident was discharged due to the need for one-to-one staffing.
A resident with dementia and behavioral issues was discharged without proper documentation or a 30-day notice. The facility failed to document conversations with the resident's family and did not provide a discharge plan, leading the family to feel forced to take the resident home.
A medication cart on the [NAME] Unit was found unlocked and unattended, contrary to the facility's policy requiring it to be locked when not in use. An RN confirmed the cart should have been locked and admitted to leaving it unattended while assisting another resident.
The facility's kitchen had several sanitation deficiencies, including unlabeled and undated food items, improper use of hair restraints by dietary staff, and inadequate testing of sanitizer levels. Additionally, ice scoops were stored improperly, posing a risk of cross-contamination and foodborne illness for residents.
The facility failed to provide adequate staffing, resulting in missed resident baths and showers, and ineffective communication due to language barriers. Staff shortages led to unmet resident hygiene needs, while language difficulties hindered communication between staff and residents, requiring translators for effective interaction.
The facility did not ensure residents received mail on Saturdays, impacting all 77 residents. During a Resident Council meeting, residents noted that mail was not delivered on weekends. The Activities Director confirmed that weekend mail was held until Monday. The Administrator expected mail to be delivered to residents on weekends if received from the Post Office.
The facility failed to update care plans for four residents, omitting critical interventions such as wander guards, family assistance with ADLs, and fall mats. Despite staff awareness and physician orders, these updates were not reflected in the care plans, as confirmed by the DON.
A resident with a self-care deficit due to fractures did not receive adequate bathing assistance as per her care plan, which required showers at least once a week. Documentation showed inconsistencies, with the resident receiving fewer baths than scheduled. Interviews revealed that staffing issues led to missed bathing opportunities, and the resident expressed a desire to bathe daily. The DON confirmed the deficiency in documentation and service provision.
A resident with quadriplegia and other conditions did not receive recommended restorative physical therapy services due to the facility's failure to provide these services. Despite an occupational therapy assessment recommending a passive range of motion program, the resident reported not receiving the exercises. Interviews with staff revealed the absence of a restorative nursing aide and a lack of therapy services offered to the resident.
The facility failed to provide necessary behavioral health care for two residents with depression, as effective communication with psychiatric providers was lacking. One resident was not seen by the psychiatric provider after an initial visit, and the other showed worsening depression without being offered talk therapy. The Social Services Director was unaware of the psychiatric services provided, and the psychiatric provider only offered medication management on an as-needed basis.
The facility failed to ensure that four residents had completed and signed consent or refusal forms for pneumococcal and influenza vaccines. The records lacked documentation of education on the benefits and side effects of the vaccines, and interviews with the IP and DON confirmed the absence of these forms in the residents' medical charts.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. Two CNAs did not complete the necessary training hours despite working multiple shifts. The facility administrator confirmed the deficiency during interviews.
The facility failed to honor the choices of two residents. One resident was not allowed to have his pacemaker monitor in the facility, despite its importance for monitoring his heart condition. Another resident, who required assistance with bathing, was not provided showers according to his preference of three times a week, as confirmed by grievances and staff interviews.
A resident at high risk for falls experienced three falls in one day, resulting in a neck fracture. The facility failed to conduct required post-fall neurological assessments after the first and second falls, despite the resident's known tendency to self-transfer due to communication difficulties. Staff interviews confirmed the lack of adherence to the facility's policy for frequent assessments following falls.
A resident was inappropriately fitted with a WanderGuard despite not attempting to leave the facility grounds and lacking a physician's order for it. The resident's care plan and elopement risk evaluation did not justify the use of the device. Interviews with the DON and RRN revealed that the resident was not at risk for elopement, and the use of the WanderGuard was a preventative measure, leading to a deficiency in promoting care with dignity and respect.
A resident with a history of skin breakdown and infections around the stoma did not receive consistent ileostomy care as per physician orders. The resident frequently had soiled clothing and bed linens, and the stoma area was red and excoriated. Despite complaints of discomfort, the nursing staff did not consistently apply the ostomy bag or abdominal binder, leading to inadequate care and potential risk for further skin complications.
A facility failed to accurately complete an Elopement Risk Evaluation for a resident, resulting in a moderate risk score despite inconsistencies in the assessment. The evaluation indicated cognitive impairment and occasional outdoor ambulation, but the 'Imminent Risk' section was left blank. Interviews with the DON and a Regional RN revealed differing views on the resident's elopement risk, with the DON noting the resident's frequent desire to go home but easy redirection, while the RN stated the resident was not at risk.
A resident's room was found to be dirty and sticky, with food crumbs, an unknown yellow liquid, and urinals improperly placed. The resident reported infrequent cleaning by housekeeping staff. An LPN and the Administrator confirmed that the room should have been cleaned daily, and the presence of debris and used medical equipment was inappropriate.
The facility failed to respect resident choices by using bladder control pads in briefs without consent. Interviews revealed CNAs used these pads to prevent leakage, often without asking residents. Two residents expressed discomfort and dissatisfaction with the pads, which were not part of their care plans. Some staff, including the DON, were unaware of this practice.
A resident with multiple diagnoses, including a history of falls, experienced several falls over a period of time without updates to their care plan. Despite discussions in IDT meetings, the care plan remained unchanged, failing to reflect the resident's current needs. The facility's ADM and DON acknowledged the oversight, noting the care plan did not incorporate necessary interventions.
Failure to Track and Communicate Resolution of Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were consistently tracked, resolved, and communicated back to residents. During a resident council meeting, one resident reported that residents were not being notified about how or when their submitted grievances were resolved, stating that grievances were turned in but never followed up on. This resident identified several unresolved issues, including problems with communication with kitchen staff, who were described as Spanish-speaking only and not following resident meal tickets, and the absence of dietary staff, including the dietary manager, from resident council meetings despite being invited. Additional unresolved concerns included residents not being transported to their appointments, uncertainty about whether this was due to low staffing in the transport department, laundry not being returned, and a lack of hot water for at least six months. Another resident reported not receiving showers because there was no hot water. The same resident who raised multiple concerns also stated that there was no official grievance official, which she believed contributed to residents not receiving responses about resolutions to their grievances. In a subsequent interview, the Regional Nurse Consultant stated that the Social Services Director or the Administrator were responsible for following up on grievances, that the Social Services Director was designated as the grievance official, and that the facility’s expectation was for all grievances to be addressed and resolved within five working days. Despite this stated process, the residents’ reports indicated that grievances were not being followed up on or communicated back to them.
Failure to Maintain Safe, Clean Environment and Consistent Hot Water Access
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, including consistent access to hot water. Surveyors observed that water temperature logs in the kitchen had not been updated since 01/07/26, and the dishwashing machine water temperature was only 80 degrees with significant hard water buildup and missing temperature logs. Hot water temperatures measured in multiple resident rooms ranged from the low 70s to low 80s, below the Administrator’s stated expectation of 90–108 degrees, with only two rooms reaching 94 degrees. The Dietary Manager acknowledged falling behind on updating dishwashing temperature logs, and staff interviews confirmed ongoing issues with the boiler and hot water system. Residents reported prolonged and recurrent problems with hot water availability, particularly at night. One resident stated he had been trying to get a shower but the water remained cold, and that the issue had been ongoing for about seven months, including during Christmas. He reported being told that staff turned the hot water off at night and that some elderly residents were not being showered for weeks because their showers were scheduled at night. Another resident reported that the lack of hot water had been occurring for about six months, that residents scheduled for night showers either did not receive showers or received cold showers, and that staff advised residents to request boiled water from the kitchen for washing up. Facility staff, including a CNA and an LPN, confirmed that residents complained about no hot water for showers and that the water system and boiler had been problematic for some time. The facility also failed to maintain the dining room and resident rooms/restrooms in a homelike manner and in good repair. In the main dining room, surveyors observed a missing ceiling tile with exposed wiring, adjacent tiles with brown water spots, unsecured television and projector cords hanging near resident dining tables, and ceiling vents over resident tables covered with dust buildup. In resident rooms, observations included broken window blinds, a slow-draining sink, blood-like smears on a wall, missing outlet covers near beds, an exposed light bulb with missing housing near a doorway, and light fixtures filled with dead insects. Multiple resident showers were used for storage of items such as sit-to-stand lifts, bedside commodes, wheelchairs, and other random items. The Administrator acknowledged that light fixtures should not be full of dead insects, there should be no exposed bulbs or broken/missing outlet covers, vents over dining tables should be clean, and that maintenance was expected to address these issues in a timely manner.
Failure to Obtain Orders for Respiratory Equipment and Missed Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure services met professional standards of quality for two residents. For one resident using respiratory medical equipment, the Regional Nurse Consultant (RNC) reported that the resident’s family brought in outside medical equipment that was not ordered by a physician. The RNC stated that staff should be aware of what medical equipment the resident possesses and ensure there are physician orders for those devices, confirming that this was not done. This resulted in the resident using and storing respiratory medical equipment in the facility without corresponding physician orders. For another resident, the facility did not follow the care plan for weekly skin assessments. The resident’s care plan, dated 08/25/25, identified the resident as being at risk for pressure ulcers due to impaired mobility and fragile skin, with an intervention requiring a licensed nurse to assess the resident’s skin at least weekly and report any changes. Review of the electronic health record showed that no weekly skin assessment was documented from 12/22/25 until 01/11/26, a gap of three consecutive weeks. An LPN stated that nurses are supposed to complete head-to-toe assessments every week, and the Wound Care Nurse confirmed that facility nursing staff should have completed weekly skin assessments for this resident but did not. The RNC also confirmed that the weekly skin checks for this resident should not have been missed.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for 3 of 5 randomly reviewed CNAs, specifically CNAs #4, #6, and #7. Record review of the staffing list showed that CNA #4, hired on 10/20/17, CNA #6, hired on 12/01/21, and CNA #7, hired on 10/05/22, were all still employed at the facility. When surveyors requested CNA annual performance reviews, there were no completed annual performance reviews available for these three CNAs. During an interview, RN #3 stated he had recently been put in charge of CNA training and annual performance reviews and confirmed that each CNA is required to complete an annual performance review. In a separate interview, the Regional Nurse Consultant confirmed that CNAs #4, #6, and #7 did not have annual performance reviews completed and that they should have had them. According to the report, if the facility is not completing a performance review of every CNA at least once every 12 months, then residents are likely to not receive the appropriate care and services, and the CNAs may not meet the needs of all residents.
Medication Error Rate Exceeds 5% Due to Improper Crushing and Missed Inhaler Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 11.54% error rate based on 3 errors out of 26 observed medication administrations involving three residents. One resident received divalproex sodium (Depakote) 500 mg delayed-release tablets crushed by an RN, despite this being a delayed-release formulation. The medication package label for this resident’s divalproex sodium did not state “do not crush,” and the physician’s order for Depakote did not include any notation about crushing. A separate provider order for this resident allowed crushing oral medications “if indicated” and mixing with applesauce, but there was no specific order indicating a medical need to crush the delayed-release divalproex sodium. Another resident did not receive ordered doses of Symbicort 160/4.5 mcg inhaler, with surveyors identifying six missed doses over several days. During medication pass observation, the RN reported the inhaler was not available, was not in the emergency medication machine, and that the facility was awaiting pharmacy delivery. A third resident received phenytoin sodium extended-release oral capsules in crushed form, administered by an RN who crushed the extended-release capsule prior to giving it. The physician’s orders for this resident allowed crushing medications and/or opening capsules “if indicated,” but there was no order documenting a medical need to crush phenytoin, and the phenytoin medication package label specifically stated “do not crush.” The DON later confirmed that facility expectations and policy are that extended/delayed-release or enteric-coated medications are not to be crushed unless there is a specific medical order to do so, and also confirmed that the process for addressing the missing Symbicort doses had not been followed.
Expired Lancets Found in Medication Storage Room
Penalty
Summary
Surveyors identified a deficiency related to improper storage and management of medical supplies in the medication storage room serving the 400, 500, and 600 halls. During an observation on 01/13/26 at 12:36 PM, a box of ReliOn Ultra Thin Lancets, which are small single-use needles used to puncture skin for capillary blood sugar checks, was found in a drawer with blood glucose checking equipment, bearing an expiration date of 10/2023. In a subsequent interview at 12:38 PM, an RN confirmed that the ReliOn Ultra Thin Lancets were expired and stated he was unaware of the facility’s policy regarding medical supply expiration dates, though he believed they should be discarded. Later, at 1:37 PM, the DON stated her expectation that staff do not use any expired products and that all expired medications should be disposed of, and further stated that lancets should be thrown away when expired, otherwise they can be used for care. The report states that this deficient practice is likely to result in expired medical equipment being used for resident care leading to potential infection risk, as sterility is lost over time allowing introduction of bacteria.
Failure to Serve Meals Consistent With Menus and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide meals consistent with posted menus, diet orders, and documented food preferences for all five residents reviewed for dining, with specific examples involving two residents. One resident with chronic respiratory failure with hypoxia had a physician’s order for a heart healthy, regular texture diet. At lunch, her meal ticket included a request for a salad in the additional notes, but observation showed she did not receive a salad. She reported that she asked kitchen staff about the missing salad and was told there was no salad available for her. The dietary aide confirmed the resident did not receive a salad because the kitchen did not have one readily prepared, while both the RD and the Dietary Manager stated they expected kitchen staff to have prepared and provided the salad when requested. Another resident with muscle wasting and atrophy had no known food allergies and was on a regular diet. At lunch, her meal ticket indicated she was to receive a pork sandwich on a bun, potato salad, coleslaw, and ice cream. Observation revealed she was instead served mashed potatoes in place of the ordered potato salad. This resident stated that items listed on the food menus were often inconsistent with what was actually served and that she would have preferred the potato salad shown on the menu. The Regional Nurse Consultant confirmed that menus should have been updated and residents should have been served what was on the menu.
Food Storage, Monitoring, and Temperature Control Deficiencies in Dietary Services
Penalty
Summary
Surveyors identified that the facility failed to store, handle, and monitor food under sanitary conditions in the kitchen and food storage areas. Observations of the main refrigerator showed multiple expired items, including a gallon of Golden Italian dressing, two gallons of lime juice, and a box of thickened apple juice past their labeled expiration dates. In the walk-in refrigerator, surveyors observed four containers of low-fat plain yogurt that were expired, an opened package of ground meat left exposed to air, and a container holding 10 broken and empty eggshells stored together with unbroken, unused eggs. In the dry storage room, an opened package of Nilla Wafers was left exposed to air. A subsequent observation of the walk-in refrigerator revealed six additional gallons of lime juice that were also expired. Surveyors also found that required temperature and maintenance logs for the dish machine PPM, kitchen refrigerator, walk-in refrigerator, and kitchen freezer were not current, with the last entries dated several days before the survey. During interview, the Dietary Manager acknowledged that no foods should be expired, that foods should be stored properly and not exposed to air, and that all kitchen staff were responsible for ensuring proper storage, non-expired foods, and up-to-date logs, but admitted he had fallen behind in updating the logs. When observed taking food temperatures for resident meal service, the Dietary Manager demonstrated uncertainty about acceptable safe food temperatures and stated he was unsure whether the temperatures obtained were safe. The Registered Dietician later stated it was her expectation that the Dietary Manager would know safe food temperatures and that all kitchen logs would be up to date, and that overall responsibility for these areas rested with both herself and the Dietary Manager.
Inadequate Infection Control in Respiratory Equipment Storage and Medication Handling
Penalty
Summary
The deficiency involves failures in infection prevention and control related to respiratory equipment storage and medication administration practices. One resident with COPD who required oxygen and used two spirometers and a nebulizer had this respiratory equipment stored improperly. During observation, one nebulizer and one spirometer were found lying on the resident’s bed and another spirometer was on a windowsill, with none of the items stored in secure bags to maintain cleanliness. A registered nurse confirmed that the equipment was not stored appropriately and stated that the respiratory equipment should be stored in bags, and the infection preventionist later stated that such equipment should be labeled, dated, and stored in a bag to maintain cleanliness. A second deficiency was observed during medication administration for another resident when an RN prepared a glucosamine 500 mg oral tablet and, upon removing it from the bubble packaging, the pill missed the medication cup and landed on top of the medication cart. The RN then picked up the pill without gloves and placed it into the medication cup with other medications. In a subsequent interview, the RN stated that protocol required discarding any pill that landed on the medication cart and obtaining a new pill from the bubble package, and she was unsure whether she had picked up and used the dropped medication. The DON stated that, regarding infection control, staff are expected to perform hand hygiene between residents, not use the same cups and supplies for multiple residents, and to dispose of any pill that lands on top of the medication cart and replace it with a new one.
Failure to Document and Educate Staff on COVID-19 Vaccination
Penalty
Summary
The facility failed to maintain required documentation related to staff COVID-19 vaccinations, including evidence that staff were provided education on the benefits and potential risks of the COVID-19 vaccine, that staff were offered the vaccine or given information on how to obtain it, and that each staff member’s vaccination status and related information were available for all staff working in the facility. During record review of infection control documentation and vaccinations on 01/15/25, surveyors found that facility staff vaccination lists were not available for review. In an interview on 01/15/26 at 1:47 p.m., the Assistant Director of Nursing, who also serves as the Infection Preventionist, stated she did not have the facility staff COVID-19 vaccination status list and that she does not provide education to staff regarding the COVID-19 vaccine. This deficient practice was cited as likely to lead to residents contracting respiratory infections and could result in the spread of infection to other residents.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration for three residents reviewed for unnecessary psychotropic drugs. For each of these residents, physician orders for psychotropic medications were in place and medications were administered, but corresponding psychotropic medication consent forms were either missing or completed only after the medications had already been started or doses changed. Pharmacist recommendations in each case explicitly stated that informed consent should be obtained at admission, prior to initiation of a psychotropic, or prior to increasing a dose, and noted that no consent forms could be found in the residents’ electronic health records. For one resident, multiple orders for Buspirone at varying doses were written and discontinued over several weeks, beginning in early October and continuing through early January. A pharmacist review in early November identified that a psychotropic consent form should be present but was not found in the record. The psychotropic medication consent form for Buspirone was later created and signed in mid-January, with the form documenting a consent date and time in early November, which was after the initial start of the medication and not contemporaneous with the actual creation and signing of the form. The ADON and the Regional Nurse Consultant both confirmed that the psychotropic consent form for this resident was not completed prior to medication administration and should have been. For a second resident, physician orders in June and August included Clonidine, Lorazepam, and Hydroxyzine for anxiety, with some orders scheduled and others as needed. A pharmacist review in mid-August again stated that informed consent should be obtained before initiation or dose increase of psychotropic medications and noted that no consent forms were present in the record. Psychotropic consent forms for Lorazepam, Clonidine, and Hydroxyzine were subsequently created and signed in September, each documenting consent dates in June, after the medications had already been ordered and used. For a third resident, Quetiapine was ordered via PEG-tube for anxiety in early November, and a pharmacist review in early December documented that a psychotropic consent form should be present but was not. The consent form for Quetiapine was later created and signed in mid-January, with a backdated consent date in early November. In interviews, the LPN stated that the ADON was responsible for completing psychotropic consent forms prior to administration, and the ADON and Regional Nurse Consultant confirmed for all three residents that the psychotropic consent forms were not completed before the medications were administered.
Threatening Text Messages and Inappropriate Physical Contact Toward a Resident
Penalty
Summary
Facility staff failed to protect a resident from abuse when the DON sent threatening text messages and a night shift nurse used inappropriate physical contact and language. The resident, who had been admitted earlier in the year, went out on approved out-of-facility leave. Nursing progress notes documented that staff believed the resident was missing after he did not answer his cellphone and his wife reported he was not with her, leading to notification of the ADM, DON, and police. During this period, the DON sent messages to the resident stating he needed to pick up his belongings because he was being discharged. The resident later reported feeling confused and threatened by these messages, and the RNC and RA acknowledged the messages were inappropriate and that the resident interpreted them as a threat. When the resident returned from leave, nursing notes documented his return without complaints of pain or discomfort, but the resident later reported that the night shift nurse entered his room, hit or tapped his foot, and used foul language toward him. He stated this made him feel like a child, intimidated, and that he did not like this treatment. He reported these concerns to an ADON, who confirmed the resident’s report that the nurse had tapped his foot and that the resident did not like that treatment. Another ADON was aware of the resident’s statement that the nurse used foul language and hit his feet. The RNC stated the nurse had been “lecturing” the resident and tapping his foot in what was described as a friendly manner, but confirmed the nurse should not have tapped the resident’s feet, especially since the resident interpreted the act as abusive, and also confirmed the DON’s text messages were inappropriate.
Inaccurate PASRR Level 1 Screening for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) Level 1 screening was completed for one resident at admission. Record review showed that this resident’s face sheet listed diagnoses of unspecified dementia, moderate, with agitation, and bipolar disorder, unspecified, at the time of admission. However, the PASRR Level 1 form completed for this resident indicated that the resident did not have a mental illness diagnosis. During an interview, the Admissions Coordinator stated that she and the admissions liaisons were responsible for reviewing PASRRs upon admission and ensuring they were accurately completed, acknowledged that the PASRR documented no mental health diagnosis despite the resident’s bipolar disorder diagnosis, and stated it was her expectation that this inaccuracy should have been identified and corrected at admission. This discrepancy between the admission documentation and the PASRR Level 1 screening, and the failure of the admissions staff to identify and correct the error during their review process, led to the cited deficiency for not accurately assessing the resident’s mental health status at admission as required.
Failure to Update Care Plan for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to revise the comprehensive care plan to include a resident’s prescribed oxygen (O2) therapy. Record review showed the resident was admitted on a specified date and had a physician’s order dated 12/16/25 for O2 at 2 LPM via nasal cannula. However, review of the resident’s care plan dated 12/23/25 revealed that O2 use was not included as a care-planned intervention. During an interview, a CNA confirmed that the resident wears O2 every day, and the Regional Nurse Consultant acknowledged that the resident’s care plan should include O2 use but did not. The report states that if the facility is not updating the care plan to reflect the resident’s current care areas and treatment, then the facility may not be providing appropriate care and treatment to meet the resident’s needs. These findings demonstrate that despite an active physician order and daily use of O2, the resident’s care plan was not updated by the interdisciplinary team within the required timeframe to reflect this treatment, resulting in a deficiency related to care plan revision and coordination of care.
Failure to Follow PRN Oxycontin Pain-Level Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide pain management in accordance with professional standards and the physician’s orders for one resident receiving oxycontin for pain. The resident reported that at times the facility did not have his pain medication available and had to obtain it from the emergency supply. Physician orders dated 12/16/25 and 01/05/26 specified oxycontin 5 mg by mouth every four hours as needed for severe pain, to be used only when the resident’s pain level was 8 or above on a 0–10 pain scale. The pain scale defined 8 as very strong pain, 9 as intense pain with inability to converse, and 10 as the worst pain possible. Medication Administration Record review showed that staff repeatedly administered oxycontin when the resident’s documented pain scores were below the ordered threshold of 8. In December, oxycontin was given on multiple dates when pain levels were recorded as 5, 6, and 7, and in January it was administered when pain levels were documented as low as 2 and 3, as well as 5 and 6. During interview, an RN acknowledged she was not used to following physician orders that specified a particular pain level and confirmed that all administrations with pain levels under 8 did not follow the physician’s orders. The Regional Nurse Consultant also confirmed that the oxycontin orders had not been followed when the medication was administered for any pain level under 8.
Failure to Obtain and Administer Prescribed Inhaler Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain and provide a prescribed inhaled medication, Symbicort 160-4.5 mcg/act (budesonide/formoterol), for a resident. During a medication pass observation, an RN did not administer the Symbicort inhaler because it was not available and was not stocked in the Rx Now emergency medication machine. The RN reported having contacted the pharmacy and was awaiting delivery of the inhaler. Medication administration records for this resident showed multiple missed doses of Symbicort, including an evening dose on 01/10/26, both morning and evening doses on 01/11/26 and 01/12/26, and the morning dose on 01/13/26. During an interview, the DON stated that staff are expected to administer missed medications as soon as possible and to notify her if multiple days pass without a medication so she can contact the pharmacy and provider for medication or an alternative. The DON also explained there is an emergency kit for one-time usage and that if a medication is not present there, staff are to call the pharmacy immediately, as there is an agreement with a local pharmacy to obtain medications quickly. The DON confirmed that this process was not followed for the resident’s Symbicort inhaler and acknowledged that multiple doses of the medication were missed.
Failure to Submit Timely Investigation Results to State Agency
Penalty
Summary
The facility failed to submit the results of an investigation into allegations of abuse, neglect, or injuries of unknown source to the State Agency within the required five working days. Record review showed that the five-day follow-up report was not sent for one resident involved in an investigation. During an interview, the facility's Administrator confirmed that the five-day follow-up had not been submitted to the State Agency as required.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple complex medical conditions, including acute kidney failure, hydroureter, obstructive and reflux uropathy, and a history of prostate cancer. The resident, who had moderate cognitive impairment, was reported by his family member to have experienced rough handling by a male staff member while being provided with dry blankets, which allegedly resulted in the pulling of a tube and subsequent transfer to an acute care hospital. The administrator, who served as the abuse coordinator, interviewed the involved staff and the resident, but concluded the incident occurred at another hospital based on her interview with the resident, despite the family member's clarification that the event took place at the facility. The administrator obtained written statements from the staff involved and interviewed the resident at the hospital, but did not pursue further investigation after her initial conclusion. The family member had specifically reported the incident as occurring at the facility, and the staff member identified as being involved confirmed familiarity with the resident and described care provided during the relevant shift. The lack of a comprehensive investigation into the abuse allegation constituted a failure to respond appropriately to the reported violation.
Sanitation and Mask Compliance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, as observed during a survey. Opened food items in the refrigerator, freezer, and dry storage room were not dated or labeled, including a tray of glasses with an unidentified orange liquid, a bag of cut red onions, and a tray containing five salads. Eggs and cheese were left out of the refrigerator for an hour, leading to potential foodborne pathogen growth. Additionally, the dry storage room floor was dirty, and the steam table had calcium build-up and food particles. The Dietary Aide was observed cleaning food service areas with the same dishcloth without using a sanitizing solution. Furthermore, the facility did not ensure that kitchen staff wore face masks appropriately during a respiratory virus outbreak. A Dietary Aide was seen wearing his mask below his nose while preparing food, contrary to the requirement for masks to be worn at all times in the facility. The Dietary Manager confirmed these findings and acknowledged the improper mask usage and the unsanitary conditions in the kitchen.
Failure to Notify Residents and Families of Room Changes
Penalty
Summary
The facility failed to provide written notice for room changes to two residents, resulting in a deficiency. The first resident, who had severe cognitive impairment and multiple medical conditions including dementia and schizophrenia, was moved from one unit to another without any documented notification to the resident's family. The resident's daughter discovered the move during a visit and expressed her expectation that the facility should have informed her about the room change. The second resident was also moved without notification, reportedly due to room painting. The resident expressed confusion and concern about the move and the whereabouts of her belongings. A CNA confirmed the move and the reason but was unsure if the resident was informed. The Director of Nursing and the Administrator acknowledged the protocol for notifying residents and families but could not provide documentation of such notifications for these room changes.
Failure to Maintain Functional Oxygen Concentrators
Penalty
Summary
The facility failed to ensure that three residents had working portable oxygen concentrators, which is essential for maintaining adequate oxygen levels in the blood. For Resident #5, the oxygen concentrator was found not to be functioning during an observation, and the resident's oxygen saturation was measured at 82%, which is below the ideal range of 95% to 100%. The resident reported having trouble breathing, but it was unclear how long the concentrator had been malfunctioning. Similarly, Resident #6's portable oxygen concentrator was not working, and the resident appeared cyanotic and lethargic, with an oximeter unable to read their oxygen level. The MDS Director confirmed the concentrator's malfunction and noted the resident's reduced alertness. Resident #7 also had a non-functioning oxygen concentrator, with an initial inability to obtain an oxygen level reading. Upon further assessment, the resident's oxygen saturation was found to be 89%, which is below the desired range. An anonymous caller reported the issue to the Director of Nursing, who was informed but reportedly did not take action. Interviews with staff, including a CNA and the Director of Nursing, highlighted the expectation that all residents should have working oxygen concentrators, with checks performed throughout the day. However, the deficiency in ensuring functional equipment was evident, as the concentrators for these residents were not operational.
Failure to Notify Providers of Resident's Behavioral Changes
Penalty
Summary
The facility failed to notify the Providers, including Physicians and Nurse Practitioners, of a change in condition for a resident who began exhibiting behaviors. The resident, who had a history of drug-induced secondary Parkinsonism, dementia, disorganized schizophrenia, and cognitive communication deficit, was documented to have no behavioral issues in the Minimum Data Set (MDS) assessment. However, behavior charting revealed that the resident attempted to encourage female residents to come to his room, held their hands, and kissed them. Despite these ongoing behaviors, there was no documentation indicating that the resident's physician was notified. Interviews with the medical doctor and the Director of Nursing confirmed that the facility did not communicate the resident's behaviors to the physician, which was expected for ongoing issues. The medical doctor stated that while a one-time incident might not require notification, ongoing behaviors should have been communicated to discuss further interventions. The Director of Nursing acknowledged the lack of documentation regarding communication with the provider, highlighting a deficiency in the facility's protocol for notifying providers of significant changes in a resident's condition.
Failure to Investigate Alleged Inappropriate Behavior
Penalty
Summary
The facility failed to conduct and document a thorough investigation into an alleged incident of inappropriate behavior involving two residents. The incident occurred in the dining room where one resident kissed another resident on the lips, witnessed by the latter's husband. The husband reported the incident to the staff, but the facility's administrator did not verify the occurrence with other residents or staff members and relied solely on the husband's statement. The administrator acknowledged the lack of documentation and investigation into the incident. Additionally, the resident involved in the incident had a history of inappropriate behavior, as noted in behavior charting and nursing progress notes. The resident had previously attempted to encourage female residents to visit his room and had been redirected multiple times. Despite these documented behaviors, the facility did not provide documentation of investigations into these incidents. The resident was eventually discharged due to the need for one-to-one staffing, but the lack of thorough investigation and documentation of the incidents was a noted deficiency.
Inadequate Documentation and Communication in Resident Discharge
Penalty
Summary
The facility failed to include required information in the medical record for the transfer or discharge of a resident, identified as R #1. The resident had a history of drug-induced secondary Parkinsonism, dementia with behavioral disturbances, disorganized schizophrenia, and cognitive communication deficits. The Minimum Data Set (MDS) indicated that the resident did not display physical or verbal behaviors toward others prior to discharge. However, the discharge summary noted that the resident was discharged home at the administration's discretion without proper documentation of behaviors leading to this decision. Interviews revealed that the facility's administration decided to transfer the resident due to concerns about inappropriate behaviors, such as kissing and touching other residents. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the facility could not provide the necessary one-to-one care for the resident. Despite attempts to contact the resident's daughter, who was the Power of Attorney (POA), the facility did not provide a 30-day discharge notice. The daughter felt forced to pick up her father due to the lack of communication and documentation regarding the discharge plan. The ADM and DON admitted to not documenting conversations with the resident's daughter or the facility's regional staff about the discharge. The facility had initiated one-to-one staffing for the resident for five days before the discharge but did not explore or document other interventions. The ADM confirmed that no discharge plan was documented, and the decision to discharge was made without proper documentation or communication with the resident's family.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a medication cart on the [NAME] Unit remained locked when not in use, as required by their Security of Medication Cart Policy dated April 2007. During an observation, the medication cart was found unlocked and unattended, with no nursing personnel present, while residents were walking around and sitting close to it. This was confirmed by an interview with a Registered Nurse (RN) who acknowledged that the cart should have been locked at all times when not in use. The RN admitted to stepping away to assist another resident and was aware of the requirement to lock the cart.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, leading to several deficiencies. Observations revealed that food items in the Dietary Department refrigerators and freezers were not labeled or dated, including a bowl of ice cream, a tray of clear liquid glasses, a bag of radishes, and several other food items. This lack of labeling and dating could lead to cross-contamination and the growth of foodborne pathogens. During an interview, the Dietary Manager confirmed that all food items should be labeled, dated, and protected from air. Additionally, dietary staff did not utilize proper hair restraints, as observed with two dietary aides who did not wear hairnets or beard guards, despite having hair over one inch in length. The facility also failed to ensure that staff knew how to test the sanitizer level in a sanitizing bucket, with one dietary aide unaware of the proper procedure and strength required. Furthermore, ice scoops were improperly stored on top of a dusty ice machine, which the Dietary Manager acknowledged should not occur. These failures collectively posed a risk of cross-contamination and foodborne illness for all residents consuming food from the kitchen.
Staffing and Communication Deficiencies
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of all 77 residents, resulting in missed baths and showers. Interviews with staff members revealed that due to short staffing, residents often did not receive their scheduled baths or showers. CNAs reported that there were not enough staff members to assist with resident hygiene and respond to call lights, especially when two staff members were needed to assist a resident. This lack of staffing was confirmed by multiple staff members who noted that the facility frequently experienced staffing shortages. Additionally, the facility failed to ensure effective communication between staff and residents. A resident expressed frustration during morning care because staff did not understand his needs due to language barriers. Another resident reported that staff did not speak English during care, leading to misunderstandings. Interviews with CNAs revealed that some staff members had difficulty speaking English and required translators to communicate effectively with residents. The facility administrator acknowledged that not all staff could communicate with residents and emphasized the need for translators to prevent delays in care.
Failure to Deliver Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, affecting all 77 residents residing at the facility. During a Resident Council meeting, residents expressed that staff did not deliver mail on weekends, although they believed it should be delivered. An interview with the Activities Director confirmed that mail delivered by the Post Office on weekends was placed in the activities mailbox and not distributed to residents until Monday. The Administrator stated that the expectation was for residents to receive their mail on weekends if it was delivered by the Post Office to the facility.
Care Plan Deficiencies in Resident Safety and Assistance
Penalty
Summary
The facility failed to update the care plans for four residents, leading to deficiencies in addressing their care needs. For two residents, the care plans did not include the use of a wander guard, a device intended to prevent wandering or elopement. Despite the presence of physician orders and observations confirming the use of the wander guard, the care plans remained unupdated. Interviews with the Director of Nursing confirmed the oversight in updating the care plans to reflect the use of the wander guard for these residents. Another resident's care plan failed to document the resident's preference for family assistance with activities of daily living, specifically bathing. Despite the resident's expressed preference and the staff's awareness of this preference, the care plan did not reflect the involvement of the resident's sister in providing this assistance. Additionally, a fourth resident's care plan did not include the use of a fall mat, which was implemented after the resident experienced falls. The Director of Nursing acknowledged that the care plans should have been updated to include these interventions but were not.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident, specifically in the area of bathing and showering. The resident, who had a self-care deficit due to a history of fractures, was dependent on staff for bathing. According to the care plan, the resident was to receive a shower at least once a week and as needed. However, documentation revealed inconsistencies in the number of baths or showers provided. For the month of August, the resident was documented to have received only four baths or showers out of nine scheduled opportunities, and in September, only four out of six scheduled opportunities were fulfilled. Interviews with the resident and staff confirmed the deficiency. The resident expressed that her baths and showers had significantly reduced due to staffing issues, and she desired to bathe daily if possible. A CNA corroborated that the resident did not refuse baths or showers and wanted them daily, but missed opportunities were due to staffing shortages. The Director of Nursing acknowledged that the resident's baths and showers should have been documented both on shower sheets and in the electronic health record, confirming that the resident did not receive the necessary assistance as per her care plan.
Failure to Provide Recommended Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative physical therapy services as recommended by the therapy department for a resident diagnosed with encephalopathy, muscle weakness, and quadriplegia. The resident was admitted to the facility with these conditions and required assistance with activities of daily living due to quadriplegia. An occupational therapy assessment recommended a passive range of motion restorative nursing program for the resident's upper extremities and neck. However, the resident reported not receiving the range of motion exercises from the nursing staff, which she expected and desired. Interviews with facility staff, including an LPN, CNA, CMA, the Director of Rehabilitation, and the Director of Nursing, revealed that the facility no longer had a restorative nursing aide and had not provided the recommended therapy services to the resident. The Director of Nursing acknowledged that the facility should have offered restorative nursing services when the occupational therapy referral was made, but they did not. This lack of action resulted in the resident not receiving the necessary care to maintain or improve her range of motion and mobility.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure effective communication between the facility and psychiatric providers, resulting in two residents not receiving necessary behavioral health care to meet their needs. Resident #12, diagnosed with depression, was not seen by the psychiatric services provider after an initial visit for medication management. Despite expressing feelings of depression and a desire to talk to someone, the resident did not receive talk therapy services. The Social Services Director was unaware of the psychiatric services offered to the resident, and the psychiatric services provider confirmed that talk therapy was not provided, only medication management on an as-needed basis. Similarly, Resident #62, also diagnosed with depression, was not offered talk therapy despite showing signs of worsening depression. The resident expressed feelings of sadness and a lack of interest in activities, and the Social Services Director acknowledged the resident's need for talk therapy but was unaware of the psychiatric services provided. The psychiatric services provider's notes indicated continued medication management but did not mention any offer of talk therapy. Both residents' care plans included monitoring for depression, but the facility did not provide consistent psychiatric services to address their needs.
Missing Consent/Refusal Forms for Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five residents reviewed for immunizations had completed and signed consent or refusal forms on file to show they consented to or declined the pneumococcal and influenza vaccines. This deficiency was identified through record reviews and interviews. The facility's policies and procedures for pneumococcal and influenza prevention and control, revised in June 2020, require that a resident's medical record include documentation indicating whether the resident consented to or refused vaccinations. However, the records for the residents in question lacked this documentation. Specifically, the immunization records for the residents showed that some received the flu vaccination, while others refused the pneumococcal vaccination. However, there was no documentation of the provision of education regarding the benefits and potential side effects of the immunizations, nor was there documentation of the refusal or medical contraindication of the immunizations. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the consent/refusal forms were not present in the residents' medical charts, as required. The DON admitted to not knowing the whereabouts of the missing forms, although she was involved in administering the vaccinations.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year, as evidenced by the records of two CNAs. CNA #3, hired on June 17, 2019, did not complete the required 12 hours of in-service training for the period from June 17, 2023, through June 17, 2024, despite working seven shifts in August 2024. Similarly, CNA #4, hired on April 5, 2021, did not complete the required training hours for the period from April 5, 2023, through April 5, 2024, while working 11 shifts in September 2024. The facility administrator confirmed the lack of compliance with the training requirements for both CNAs during interviews conducted on September 26, 2024.
Failure to Honor Resident Choices for Medical Equipment and Personal Care
Penalty
Summary
The facility failed to accommodate a resident's choice to have his pacemaker monitor present in the facility. The resident, who was admitted with a diagnosis of atrial fibrillation and had a pacemaker implanted, expressed a desire to have his pacemaker monitor with him. Despite the family's request to bring the monitor into the facility, staff instructed them to wait until contacted. The monitor was crucial as it sent daily reports to the doctor's office and notified if the pacemaker malfunctioned. The Director of Nursing acknowledged the importance of having the monitor in the facility. Another resident's preference for receiving showers three times a week was not honored. The resident, who was dependent on staff for bathing, had grievances filed by his spouse due to missed showers. Documentation revealed inconsistencies in offering and providing showers, with several missed opportunities and no records of the resident refusing showers. Interviews with staff confirmed the resident's preference for regular showers and acknowledged the failure to meet this preference. The Director of Nursing confirmed that the resident and his family wanted three showers a week, which was not consistently provided.
Failure to Prevent Falls and Conduct Post-Fall Assessments
Penalty
Summary
The facility failed to prevent an accident for a resident identified as R #75, who was at high risk for falls due to spastic movement, muscle weakness, and a history of refusing help. The resident experienced three falls on the same day, with the first fall occurring in the afternoon. Despite the facility's policy requiring a post-fall assessment and monitoring, the staff did not complete the necessary neurological assessments after the first fall, which was unwitnessed and resulted in a red mark on the resident's nose, indicating a potential injury. Following the first fall, the resident experienced a second fall that reopened a laceration above his left eye. Although the resident denied pain, the incident was reported to the provider, administrator, and DON. However, the staff only completed one neurological assessment after this second fall, failing to adhere to the facility's policy of frequent assessments. The resident's condition was not adequately monitored, and the necessary interventions were not implemented to prevent further incidents. The resident suffered a third fall later that day, which resulted in a neck fracture. The resident was subsequently sent to the emergency room, where the fracture was confirmed. Interviews with staff, including LPNs and the DON, revealed that the required post-fall neurological assessments were not conducted as frequently as mandated by the facility's policy. The staff acknowledged the resident's tendency to self-transfer due to communication difficulties, yet the necessary supervision and assessments were not provided to prevent these falls and subsequent injuries.
Inappropriate Use of WanderGuard on Resident
Penalty
Summary
The facility failed to uphold the resident's rights to dignity and self-determination by placing a WanderGuard on a resident who did not attempt to leave the facility grounds. During a random observation, it was noted that the resident was wearing a WanderGuard, despite not having a physician's order for it. The resident's care plan, dated July 25, 2024, did not include any mention of the WanderGuard, and the Elopement Risk Evaluation indicated a moderate risk score but did not justify the use of a WanderGuard. The evaluation noted that the resident was cognitively impaired, could ambulate or propel themselves, and occasionally went outdoors but did not attempt to leave the grounds. Interviews with the Director of Nursing (DON) and the Regional Registered Nurse (RRN) revealed that the resident expressed a desire to go home daily but was easily redirected and had not attempted to leave the building. The DON stated that the WanderGuard was used as a preventative measure, while the RRN indicated that the resident was not at risk for elopement and should be reassessed. The lack of proper assessment and documentation regarding the use of the WanderGuard contributed to the deficiency in promoting care with dignity and respect for the resident.
Inconsistent Ileostomy Care Leads to Deficiency
Penalty
Summary
The facility failed to provide consistent ileostomy care for a resident, leading to a deficiency in care standards. The resident, who had a history of skin breakdown and infections around the stoma, was not consistently offered or applied the ostomy bag and abdominal binder as per physician orders. The resident's care plan indicated a need for regular checks to prevent skin issues, but observations revealed that the resident often had soiled clothing and bed linens, and the stoma area was red, swollen, and excoriated. Despite the resident's complaints of discomfort and pain, the nursing staff did not consistently apply the ostomy bag or abdominal binder, and the resident frequently removed the dressing herself. Interviews with the nursing staff, including the Wound Care Nurse and the Director of Nursing, confirmed that the resident often refused the ostomy bag and removed the dressings. The staff acknowledged the resident's history of skin infections and the need for frequent clothing changes due to soiling. However, during observations, the staff did not attempt to reapply the ostomy bag or binder, and the resident expressed pain during wound care. The facility's failure to adhere to the physician's orders and the resident's care plan resulted in inadequate care and potential risk for further skin complications.
Inaccurate Elopement Risk Evaluation for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Elopement Risk Evaluation for a resident, identified as R #19, which resulted in a deficiency. The evaluation, dated 7/25/24, indicated a moderate risk score of 6 for elopement. However, inconsistencies were noted in the assessment. The 'No Risk' section was completed with answers that should have concluded the assessment, yet the 'Moderate Risk' section was also filled out, indicating cognitive impairment and occasional outdoor ambulation without attempts to leave the grounds. Despite this, the 'Imminent Risk' section was left blank, and the care plan focused on educating the resident and family, engaging the resident in activities, and supervising closely. Interviews conducted on 09/26/24 with the Director of Nursing (DON) and a Regional Registered Nurse revealed differing perceptions of the resident's elopement risk. The DON acknowledged that the resident frequently expressed a desire to go home but was easily redirected and had not attempted to leave the building. The Regional Registered Nurse stated that the resident was not considered a risk for elopement. This discrepancy between the documented evaluation and staff perceptions highlights the failure to accurately assess and document the resident's elopement risk, potentially impacting the care and treatment provided.
Failure to Maintain Cleanliness in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and hygienic environment in the bedroom of one resident, identified as R #3. During an observation, it was noted that the floor of R #3's room was dirty and sticky, with food crumbs and an unknown yellow liquid present. Additionally, two urinals were found on the nightstand, and another was on the floor near the bed. R #3 expressed that the room was only cleaned sporadically by the housekeeping staff. An LPN acknowledged the room's unclean state and mentioned that housekeeping should clean each resident's room at least once daily. The facility's Administrator confirmed that residents' rooms should be swept and mopped daily and as needed, and acknowledged that food debris and used medical equipment should not have been left in R #3's room.
Failure to Honor Resident Choices in Incontinence Care
Penalty
Summary
The facility failed to honor and promote residents' choices by using bladder control pads in residents' briefs without their consent. Interviews with staff and a former employee revealed that Certified Nursing Assistants (CNAs) often placed bladder control pads in residents' briefs to prevent leakage, sometimes without asking for the residents' permission. This practice was confirmed by multiple CNAs, although some staff, including a Registered Nurse and the Director of Nursing, were unaware of the use of these pads. The Director of Nursing stated that the facility should not be using bladder control pads in addition to briefs. Two residents, identified as R #4 and R #5, expressed their dissatisfaction with the use of bladder control pads. R #5, who has hemiplegia, hemiparesis, and aphasia, stated that she did not like the pads as they were uncomfortable and that she had informed the staff of her preference. Similarly, R #4, who has anoxic brain damage and aphasia, indicated through non-verbal communication that he did not like the pads and had communicated this to the staff. Both residents' care plans included interventions for bladder incontinence, but there was no mention of using bladder control pads, highlighting a disconnect between the care plans and the practices observed.
Failure to Update Care Plan for Resident at High Risk for Falls
Penalty
Summary
The facility failed to revise the care plan for a resident identified as R #1, who was at high risk for falls. Despite multiple falls occurring between October 3, 2023, and January 3, 2024, the care plan was not updated to reflect the resident's changing needs. The care plan, dated May 10, 2024, did not include any recent falls or changes in care needs, indicating a lack of updates and interventions discussed in Interdisciplinary Team (IDT) meetings. R #1 had a history of multiple diagnoses, including urinary tract infection, transient ischemic attack, cerebral infarction without residual deficits, unspecified fall, and cognitive communication deficit. The resident experienced several falls during the stay, with incidents documented on various dates. Despite these occurrences, the care plan remained unchanged, and the facility staff did not incorporate the interventions discussed in IDT meetings into the care plan. The facility's Administrator and Director of Nursing acknowledged that R #1's care plan did not reflect the resident's needs during the specified period. They could not explain why the care plan was dated May 10, 2024, and admitted that the care plan lacked updates or interventions that were discussed in IDT meetings and reported in daily notes. This oversight resulted in the care plan not addressing the resident's current care needs and treatments.
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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