White Sands Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobbs, New Mexico.
- Location
- 5715 North Lovington Highway, Hobbs, New Mexico 88240
- CMS Provider Number
- 325040
- Inspections on file
- 23
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at White Sands Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure medications, including psychotropics, were tied to specific diagnosed conditions and that PRN psychotropic orders were time-limited. One resident with multiple mental health diagnoses was receiving divalproex and quetiapine with indications documented only as “mood stabilizer” and “mood disorder,” which the DON acknowledged were not supported by corresponding diagnoses. Another resident with peripheral vascular disease and extramedullary plasmacytoma was receiving aspirin for “prophylactic measures” and Bactrim DS for “chemotherapy,” despite having no diagnoses matching those indications. A third resident with dementia, anxiety, bipolar disorder, major depressive disorder, and seizure disorder had PRN lorazepam for anxiety and temazepam for insomnia without stop dates or documented rationale for extended PRN use.
The facility failed to accurately complete MDS assessments for two residents by not correctly coding their scheduled medications. One resident had a physician order for daily Aspirin EC 81 mg for pain, but the quarterly MDS documented that the resident did not receive scheduled pain meds, which the MDS coordinator acknowledged was inaccurate. Another resident had a physician order for Depakote 250 mg three times daily for major depressive disorder, yet the quarterly MDS indicated the resident did not receive anticonvulsant meds; the MDS coordinator confirmed Depakote is an anticonvulsant and that this MDS entry was incorrect.
Two residents were admitted with multiple complex diagnoses, including DM2, hyperlipidemia, OSA, post-MI thrombosis, C. diff enterocolitis, depression, anxiety, epilepsy, and urinary retention. For one resident, no baseline care plan was present in the EHR, and for the other, the baseline care plan contained only a date with no clinical information. In both cases, the DON confirmed that the baseline care plans were not completed accurately or within the required 48-hour timeframe.
Staff failed to follow safe food handling and hand hygiene practices during meal service, including a nurse who assisted a resident by hand and then served another resident’s meal without hand hygiene, and multiple staff who touched drink cups by the rims while serving. A CNA assisted a resident with a clothing protector and then served another resident without washing or sanitizing hands, and a hospitality aide touched a resident’s shoulder before serving another resident’s meal without hand hygiene. In an interview, an LVN confirmed that staff are expected to wash or sanitize hands after touching potentially dirty surfaces and that dishes should not be touched by the rims when serving.
Surveyors found that PASARR Level I screens were inaccurately completed for two residents with documented mental health conditions. One resident had generalized anxiety disorder among other diagnoses, yet the PASARR form indicated no suspected mental illness. Another resident had multiple psychiatric diagnoses, including delusional disorder, major depressive disorder, bipolar disorder with psychotic features, OCD, PTSD, and panic disorder, and had recently received inpatient behavioral health treatment, but the PASARR form still documented no diagnosis or suspected mental illness. The DON acknowledged that both PASARR forms were incorrect.
Surveyors found that staff failed to accurately revise and update care plans for two residents. For one resident, the care plan for enhanced barrier precautions and vision interventions contained another resident’s name, as confirmed by the DON. For another resident with bipolar disorder, Alzheimer’s disease, cataracts, generalized anxiety disorder, and insomnia, observation showed a fall mat in use by the bed, but the care plan did not document the fall mat, despite the DON’s statement that such equipment must be included in the care plan.
A resident with COPD and multiple psychiatric and neurologic diagnoses had a physician order for oxygen at 1–3 LPM via nasal cannula using an oxygen concentrator and/or tank, but the order did not specify whether the oxygen was to be administered continuously or PRN. The resident was observed using a portable oxygen concentrator in the activity room, and the DON later confirmed that the order lacked required frequency details. This omission resulted in respiratory care that was not provided in accordance with professional standards.
A resident was found using a quarter-size bed rail on the upper left side of the bed for mobility and repositioning, but record review showed there was no corresponding physician order authorizing bed rail use. During interview, the DON confirmed that no order had been obtained prior to installation, despite requirements to assess safety risks, review risks and benefits, obtain informed consent, and ensure proper installation and maintenance of bed rails.
The facility did not update its daily nurse staffing posting as required, leaving outdated information displayed. An observation found that the posted staffing data, including RN, LPN, CNA hours and resident census, still reflected the previous day. An RN confirmed that the posting had not been updated and acknowledged it should be changed each day. This failure affected the availability of current staffing information for all residents and visitors.
Surveyors found an expired vial of Naloxone 0.4 mg/mL PRN injection stored in the medication refrigerator during an observation of the medication storage room. The DON confirmed the medication was expired and should have been removed and placed in the designated pharmacy return or destruction area. Review of the facility’s Medication Storage and Expiration policy showed staff are required to regularly audit medication storage areas and remove expired medications, but this process was not followed for the Naloxone, creating a potential issue for any resident needing emergency opioid overdose reversal.
Surveyors identified failures in infection prevention and control when a CNA exited a room wearing a gown and gloves instead of doffing PPE before leaving, contrary to the IPC’s stated expectations. In a separate case, a resident admitted with C. diff and a Foley catheter had no EBP signage or PPE available near the room, despite an LVN acknowledging that EBP should have been in place for this resident.
A resident with severe cognitive impairment and a history of trauma was verbally and physically abused by a nurse aide in training, who struck the resident, covered his mouth, mocked, and threatened him during care. The abuse was witnessed by another CNA and substantiated by an audio recording, with documentation confirming the resident's fear and the aide's presence during the incident. The facility failed to protect the resident from abuse, resulting in Immediate Jeopardy.
A CNA witnessed a NAIT cover a resident's mouth, tap their mouth, and tell them to be quiet, but did not report the incident for seven days. The accused NAIT continued working during this time, and the DON was not informed until a week after the event. The delay in reporting the abuse allegation led to Immediate Jeopardy being identified by surveyors.
A nurse aide in training worked for an extended period and completed 99 shifts before obtaining required certification, exceeding the four-month limit for certification. The Human Resources Director confirmed the aide continued to work without timely certification, contrary to facility expectations.
A resident with significant mobility and cognitive impairments, who required total assistance and two-person mechanical lift transfers, was transferred by a CNA without the required second staff member. During the transfer, the resident fell from the lift, sustaining a subarachnoid hemorrhage that required hospital treatment. Documentation and interviews confirmed that facility policy and the resident's care plan, which required two certified staff for such transfers, were not followed.
A resident was given Metoprolol Succinate and Losartan Potassium outside of the prescribed blood pressure parameters, as staff administered these medications even when the resident's blood pressure readings were below the thresholds set by the physician. The DON confirmed this constituted a significant medication error, as the medications were not held or verified with the physician as required.
A treatment cart on a resident hall was observed unlocked and unattended, with no staff present in the area. An RN confirmed the cart should have been locked and secured it upon discovery. The DON also confirmed that all treatment carts are required to be locked when not in use. This situation had the potential to allow unauthorized access to medical supplies and personal health information for all residents in the affected hall.
A document listing residents and their wound care orders was left visible on a treatment cart, exposing personal health information to unauthorized individuals. The DON confirmed that this information should have been protected from view.
The facility did not provide residents with visible information on how to contact the State Survey Agency to file a complaint. Observations showed that signs were not visible inside the facility, and the Resident Council was unaware of their ability to file complaints. Only one sign was found, facing outside, and not accessible to residents.
The facility failed to maintain a clean environment in the memory care unit, as vomit was observed on the dining area floor. An LPN noted it had been there since breakfast and was awaiting cleaning by housekeeping. The DON stated nursing staff should clean bodily fluids promptly, with housekeeping disinfecting afterward. This deficiency potentially affects all 21 residents in the unit.
The facility failed to ensure accurate PASRR assessments for five residents with documented mental health disorders, including major depressive disorder, anxiety disorder, and PTSD. Despite these diagnoses, the PASRR assessments inaccurately indicated no mental illness. The Social Services Director admitted the facility did not verify the assessments' accuracy before admission, potentially affecting the residents' receipt of necessary services.
The facility failed to develop and implement accurate care plans for two residents. One resident's care plan incorrectly included a hearing deficit, while another resident's care plan included splint use without a physician's order, and the splints were not applied as observed. These inaccuracies and implementation failures could lead to staff being unaware of the residents' actual needs.
The facility failed to change oxygen tubing as required for two residents, one with severe dementia and chronic kidney disease, and another with acute respiratory failure and COPD. The tubing for one resident was not changed weekly as expected, and the other resident's tubing was not dated, despite orders for regular changes. These lapses in care put residents at risk of illness.
The facility failed to assess six residents for bed rail safety risks, lacking necessary documentation such as risk assessments, physician orders, and informed consent. Observations showed residents with bed rails installed without proper assessments, posing potential safety risks. The DON confirmed the need for quarterly assessments but could not provide evidence of their completion.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 15.63% error rate. An RN administered medications to a resident without wearing gloves or using a medication cup, using bare hands to handle the pills. The DON confirmed that staff should use gloves and medication cups, and the RN was unsure why he deviated from the usual practice.
Two residents' rights to dignity were compromised when medical assessments were conducted in the dining area during mealtime. A medical provider and an RN interrupted meals to take vital signs and administer medication, actions that were acknowledged by the DON as inappropriate.
A facility failed to maintain sanitary food storage conditions in the memory care unit. An unlabeled and undated pitcher of white liquid, likely milk from breakfast, was found on a tray in the television room, accessible to residents. A NAIT confirmed the pitcher should not have been left there, and breakfast was served earlier that morning.
The facility failed to remove expired medications and improperly stored medications after therapy completion. An expired Ultrasound Gel was found in the medication room, and medications for a resident were not removed after therapy completion. The ADON confirmed these oversights during an interview.
Failure to Ensure Diagnosed Indications and Time-Limited PRN Use for Psychotropic and Other Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure psychotropic and other medications were prescribed and documented as medically necessary to treat specific, diagnosed conditions, and to ensure PRN psychotropic medications were time-limited or had a documented duration. For one resident with multiple mental health diagnoses including unspecified mood disorder, generalized anxiety disorder, major depressive disorder, PTSD, and dementia, the record showed orders for divalproex sodium as a “mood stabilizer” and quetiapine fumarate for “mood disorder.” During interview, the DON confirmed that the stated indications of “mood stabilizer” and “mood disorder” were not supported by corresponding diagnoses in the clinical record and that these indications did not qualify as specific conditions for prescribing these medications, nor were the medications documented as treating specific diagnosed conditions. For another resident with peripheral vascular disease and extramedullary plasmacytoma, the record showed an order for aspirin with the indication “prophylactic measures” and an order for Bactrim DS with the indication “chemotherapy.” The DON confirmed that “prophylactic measures” is not a diagnosis and that the resident did not have a diagnosis for chemotherapy, and that these medications were not documented as treating specific diagnosed conditions. A third resident with dementia, anxiety, bipolar disorder, major depressive disorder, and seizure disorder had PRN orders for lorazepam for anxiety and temazepam for insomnia. The DON confirmed these PRN psychotropic medications did not have stop dates and lacked documentation of a rationale to extend their use beyond an initial limited period. The surveyors concluded these practices failed to prevent the use of unnecessary psychotropic medications and did not comply with requirements for PRN psychotropic orders.
Inaccurate MDS Coding of Scheduled Pain and Anticonvulsant Medications
Penalty
Summary
The facility failed to ensure accurate completion of the federally mandated MDS assessments for two residents, resulting in discrepancies between physician orders and the information recorded on the MDS. For one resident, record review showed a physician’s order dated 08/13/25 for Aspirin EC 81 mg by mouth in the morning for analgesia, yet the resident’s quarterly MDS indicated that the resident did not receive scheduled pain medications; during interview, the MDS Coordinator confirmed this quarterly MDS was inaccurate because the resident does take Aspirin regularly for pain. For another resident, record review showed a physician’s order dated 09/22/23 for Depakote 250 mg by mouth three times daily for major depressive disorder, but the quarterly MDS documented that the resident did not take anticonvulsant medication; the MDS Coordinator confirmed that Depakote is an anticonvulsant and that this quarterly MDS was inaccurate. These findings demonstrate that the facility did not accurately code the residents’ medication regimens on their quarterly MDS assessments, despite existing physician orders and the MDS Coordinator’s acknowledgment that the assessments were incorrect.
Failure to Complete Accurate Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to create accurate baseline care plans containing the minimum healthcare information necessary to properly care for newly admitted residents. For one resident admitted with diagnoses including type 2 diabetes mellitus, hyperlipidemia, and obstructive sleep apnea, record review of the electronic health record showed there was no baseline care plan in place. During an interview, the DON confirmed that there was not a baseline care plan for this resident and acknowledged that this did not meet her expectations. For another resident admitted with multiple diagnoses, including thrombosis of the atrium and ventricle following an acute myocardial infarction, C. difficile enterocolitis, type 2 diabetes mellitus, depression, anxiety, epilepsy, and urinary retention, the baseline care plan was found to be incomplete. The baseline care plan record contained only a date with no additional information documented. In an interview, the DON confirmed that this baseline care plan was not completed accurately and within 48 hours as expected.
Failure to Maintain Hand Hygiene and Sanitary Practices During Meal Service
Penalty
Summary
The deficiency involves failure to follow safe food handling practices and maintain sanitary conditions during meal service. During a lunch observation, a nurse assisted a resident into the dining area by holding her hand and then immediately served another resident’s lunch meal without washing or sanitizing her hands. The same nurse served meals to additional residents and repeatedly touched drink cups by the top of the rim when placing them on the tables. A certified nurse aide assisted a resident with putting on a clothing protector and then proceeded to serve another resident without performing hand hygiene. The business office manager also served meals and touched cups by the top of the rim when placing them on the tables. Additionally, a hospitality aide touched a resident’s shoulder and then served another resident’s lunch meal without washing or sanitizing his hands. During an interview, another nurse confirmed that staff are expected to sanitize or wash their hands after touching dirty surfaces and when handling food items and trays, and that staff should never touch dishes by the rim when serving. The deficient practices were identified as likely to affect all 111 residents in the facility and were cited as failures to ensure food was served under sanitary conditions and in accordance with safe food handling standards.
Inaccurate PASARR Level I Screening for Residents With Mental Illness
Penalty
Summary
The facility failed to ensure accurate completion of PASARR Level I Identification Screens for two residents with documented mental health diagnoses. For one resident, the admission record showed diagnoses including metabolic encephalopathy, generalized anxiety disorder, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. However, the PASARR form dated 08/23/25 indicated that this resident did not have a suspected mental illness diagnosis. During an interview, the DON confirmed that the resident’s generalized anxiety disorder should have been indicated on the PASARR form but was not. For another resident, the admission record listed multiple mental health-related diagnoses, including Alzheimer’s disease, delusional disorders, dementia with agitation and anxiety, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, obsessive compulsive disorder, PTSD, and panic disorder. Hospital discharge paperwork showed this resident had been admitted to and received inpatient care at a behavioral health hospital. Despite these documented conditions, the PASARR form dated 12/18/25 stated that the resident did not have a diagnosis or suspected mental illness. In an interview, the DON confirmed that this PASARR form was not correct and did not meet her expectations.
Failure to Accurately Revise and Update Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to revise and accurately maintain comprehensive care plans for two residents following their assessments. For one resident, review of the care plan dated 02/17/26 showed that focus areas related to enhanced barrier precautions and vision interventions contained another resident’s name instead of the correct resident’s name. During an interview, the DON confirmed that other residents’ names were used in this resident’s care plan. For another resident, record review showed admission with multiple diagnoses, including bipolar disorder, Alzheimer’s disease, age-related nuclear cataracts in both eyes, generalized anxiety disorder, and insomnia. During observation, this resident was seen ambulating in the room with a fall mat on the floor by the bed. However, review of the care plan dated 12/02/25 revealed no indication that a fall mat was in use for this resident. In an interview, the DON stated that any time a resident uses a fall mat it must be included in the care plan and confirmed that this resident’s care plan did not include the fall mat.
Failure to Specify Oxygen Administration Parameters in Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a resident’s oxygen order specified how it was to be administered. The resident was admitted with multiple diagnoses, including dementia, anxiety, bipolar disorder, major depressive disorder, seizure disorder, and COPD. Record review showed a physician’s order dated 02/24/26 for oxygen at 1–3 LPM via nasal cannula using an oxygen concentrator and/or oxygen tank, but the order did not indicate whether the oxygen was to be given continuously or on an as-needed basis. During an observation in the activity room on 03/10/26, the resident was seen wearing a nasal cannula connected to a portable oxygen concentrator. In a subsequent interview on 03/12/26, the DON confirmed that the oxygen order for this resident did not specify the frequency of use, such as as-needed or continuous, and acknowledged that it should have included this information. This lack of specificity in the physician’s order constituted the failure to provide respiratory care according to professional standards for this resident.
Bed Rail Installed Without Required Physician Order
Penalty
Summary
The facility failed to obtain appropriate physician orders prior to installing a bed rail for one resident reviewed for bedrails. The resident was admitted on an unspecified date, and record review of the physician orders showed no order for the use of bedrails. During an observation and interview in the resident’s room, surveyors noted a quarter-size bedrail on the upper left side of the bed, and the resident confirmed he uses the side rail for mobility and to reposition himself. In a subsequent interview, the DON confirmed that the resident did not have physician orders for the use of bedrails and acknowledged that such orders should be in place prior to installation. This deficiency occurred despite regulatory expectations that, before using a bed rail, the facility should assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bed rail.
Failure to Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post required nurse staffing information daily at the beginning of each shift, including the facility name, current date, total number and actual hours worked by RNs, LPNs, CNAs directly responsible for resident care per shift, and the resident census. On 03/09/26 at 10:01 a.m., an observation showed that the staffing data posting was still dated 03/08/26 and had not been updated for the current day. During an interview at 10:07 a.m. on the same day, an RN confirmed that the posted staffing information was dated for the previous day and acknowledged that it should be updated daily but was not. This deficient practice had the potential to affect all 111 residents, as identified by the Administrator’s census on 03/08/26, by not having current staffing information readily available to residents and visitors. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing information posting requirements and the failure to update the daily staffing data as required.
Expired Naloxone Found in Medication Storage Room
Penalty
Summary
Surveyors identified a deficiency in medication management when an observation of the medication storage room revealed a vial of Naloxone 0.4 mg/mL, 1 mL PRN injection stored in the medication refrigerator with a manufacturer’s expiration date of 12/2025, which facility staff considered expired. During an interview, the DON confirmed that the Naloxone vial was expired and acknowledged it should have been removed from the refrigerator and placed in the designated pharmacy return or destruction area. Review of the facility’s Medication Storage and Expiration policy, revised 09/2010, showed that staff are required to audit medication storage areas regularly and remove any medications that have reached their expiration date, indicating that this required auditing and removal process was not effectively carried out for this medication. This deficient practice was cited as having the potential to affect any resident requiring emergency opioid overdose reversal by providing a medication with potentially reduced efficacy.
Failure to Maintain Proper PPE Use and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices, specifically related to PPE use and Enhanced Barrier Precautions (EBP). During observation of the 300 hall, a CNA was seen exiting a resident’s room while still wearing a gown and gloves. In a subsequent interview, the CNA acknowledged that she was required to remove PPE before leaving the room and confirmed she did not follow this requirement. The Infection Prevention Coordinator stated that staff are expected to don PPE before entering a room and doff it before exiting, and that new PPE should be used each time staff re-enter a room to provide care. The facility also failed to implement EBP measures for a resident with specific infection risks. An observation showed there was no EBP signage or PPE available near this resident’s door or room. Record review revealed the resident had been admitted with enterocolitis due to Clostridium difficile and urinary retention. During an interview and observation, the resident confirmed admission with a C. diff diagnosis and the presence of a Foley catheter. An LVN confirmed that EBP should have been in place due to the resident’s current use of a catheter and diagnosis of C. diff, but these measures were not evident near the resident’s room.
Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, dementia, anxiety disorder, legal blindness, and cerebrovascular disease was subjected to verbal and physical abuse by a nurse aide in training during care. The resident was fully dependent on staff for emotional, intellectual, physical, and social needs, and had a self-care deficit related to activities of daily living. The abuse included the aide striking the resident on the mouth, telling him to hush, covering his mouth with her hand, aggressively placing him in a sit-to-stand machine, and instructing him to urinate in his brief. These actions were witnessed by another certified nursing assistant, who provided both a written statement and an audio recording of the incident. The audio recording captured the aide yelling at the resident to hush and shut up, mocking him, making threatening statements, and giving harsh instructions. The aide admitted to telling the resident to hush and to playfully tapping him, but denied hitting him. Documentation also indicated that the resident expressed fear of a staff member, though he was unable to recall the specific incident during a later interview. The resident's trauma-informed assessment revealed a history of childhood trauma, ongoing feelings of fear and helplessness, and a tendency to try to forget past traumatic events. The incident was reported to facility leadership, and the aide's timecards confirmed her presence during the dates in question. The facility's documentation included witness statements, progress notes, and the audio recording, all substantiating the occurrence of abuse. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident from abuse, resulting in likely emotional distress and trauma.
Removal Plan
- R #4 was assessed by using a Trauma Informed Assessment. No immediate concerns noted.
- Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.
- Safe survey for all facility residents were initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe.
- Referral for additional spiritual services for support within the community for R #4 via hospice team.
- R #4's Care Plan updated for trauma-informed care.
- All staff were re-educated on: Abuse and neglect definition, signs and symptoms of abuse and reporting and when to report; Zero-tolerance expectation; Resident rights; Mandatory reporting within 2 hours.
- Staff training was conducted for all facility staff.
Failure to Timely Report Alleged Abuse and Remove Accused Staff
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe. A Certified Nurse Aide (CNA) witnessed a Nurse Aide in Training (NAIT) cover a resident's mouth with her hand, tap the resident's mouth, and tell the resident to "shut up." This incident occurred on 08/22/25, but was not reported to facility management until 08/29/25, seven days later. During this period, the accused NAIT continued to work in the unit, potentially exposing other residents to risk. The CNA who witnessed the incident did not immediately report it, stating she was unsure of what to do, and only informed a Registered Nurse (RN) after several days had passed. The RN, upon learning of the incident, immediately reported it to the Unit Manager, who then notified the Director of Nursing (DON). The DON confirmed that the facility did not become aware of the allegation until seven days after the event and that the initial report to the State Agency was also delayed. Timesheet records confirmed that the accused NAIT continued to work during the period between the incident and the report. The delay in reporting resulted in the identification of Immediate Jeopardy by surveyors.
Removal Plan
- R #4 was assessed by using a Trauma Informed Assessment.
- Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.
- Safe survey for all facility residents was initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe.
- Referral for additional spiritual services for support within the community for R #4 via hospice team.
- R #4's Care Plan updated for trauma-informed care.
- All staff were re-educated on abuse and neglect definition, signs and symptoms of abuse and reporting and when to report, zero-tolerance expectation, resident rights, and mandatory reporting within 2 hours.
- Staff training was conducted for all facility staff.
Failure to Ensure Timely Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide in training completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of employment. Record review showed that one nurse aide was hired and began working as a nurse aide in training, but did not receive certification until more than six months after starting, during which time the aide worked a total of 99 shifts. The Human Resources Director confirmed that the aide received certification late and continued to work during this period, contrary to the facility's expectation that all nurse aides become certified within four months.
Failure to Use Required Two-Person Assistance During Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow established protocols for safe resident transfers, resulting in a fall and serious injury. A resident with multiple diagnoses, including Alzheimer's disease, repeated falls, Parkinson's disease, and muscle weakness, required total assistance for transfers and was care planned to be transferred using a mechanical lift with two staff members. Despite this, a Certified Nursing Aide (CNA) attempted to transfer the resident alone using a mechanical lift, while a Hospitality Aide was present in the room only for one-to-one monitoring and did not assist with the transfer. During the transfer, the resident fell from the lift after a snapping or popping sound was heard, striking his legs and head on the lift and floor. The incident resulted in the resident sustaining a subarachnoid hemorrhage, as confirmed by a CT scan, necessitating transfer to a hospital for higher-level neurological care. Documentation and witness statements confirmed that the CNA did not obtain assistance as required by the resident's care plan and facility policy, which mandates two certified staff for mechanical lift transfers. The resident was later readmitted to the facility after hospital treatment and resolution of the hemorrhage.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
Staff failed to administer medications according to physician's orders for one resident. The physician's orders specified that Metoprolol Succinate ER 50 mg should be given once daily for hypertension, but held if the systolic blood pressure (SBP) was less than 120, diastolic blood pressure (DBP) was less than 80, or heart rate (HR) was less than 60. Losartan Potassium 100 mg was also ordered once daily for hypertension, to be held if SBP was less than 120. Despite these parameters, the Medication Administration Record (MAR) showed that both medications were administered on multiple occasions when the resident's SBP was less than 120 or DBP was less than 80, contrary to the physician's instructions. The Director of Nursing (DON) confirmed during an interview that the resident received Metoprolol Succinate and Losartan Potassium outside the prescribed parameters, constituting a significant medication error. The DON stated that the expectation is for nurses to follow the orders as written, hold the medication when indicated, and call the physician to verify instructions. The documentation and interview confirm that the medications were not administered in accordance with the physician's orders, resulting in a deficiency.
Unattended Unlocked Treatment Cart on Resident Hall
Penalty
Summary
A treatment cart located in the 200 hall was found unlocked and unattended during a random observation, with no facility employees present in the area at the time. This was confirmed by a registered nurse, who acknowledged that the cart should have been locked and proceeded to secure it. The Director of Nursing also confirmed in a subsequent interview that all treatment carts are required to be locked when not in use. The unlocked cart had the potential to allow unauthorized access to medical supplies and personal health information for all 27 residents in the affected hall. No specific information about the medical history or condition of the residents involved was provided in the report.
Resident Health Information Left Unsecured on Treatment Cart
Penalty
Summary
A deficiency occurred when a paper document containing the names of residents and their wound care orders was left face up on top of a treatment cart, making personal health information visible and accessible to unauthorized individuals. This was observed during a random facility check and had the potential to affect all 27 residents residing in the rooms on the 200 hall. During an interview, the DON confirmed that such information should be safeguarded and not left in plain view.
Lack of Visible Complaint Filing Information for Residents
Penalty
Summary
The facility failed to ensure that residents received information on how to contact the State Survey Agency to file a complaint. During a random observation, it was noted that signs or posters regarding filing a complaint with the state survey agency were not visible throughout the facility. An interview with the Resident Council revealed that they were unaware of their ability to contact the State Survey Agency to file a complaint. Further observation with the Administrator confirmed that only one sign was present, which was located on the front entrance door facing outside, and not visible to residents inside the facility. The sign was printed on a small piece of paper and was not easily accessible or visible to residents within the facility.
Failure to Maintain Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the memory care unit, as evidenced by the presence of vomit on the floor in the dining area. This was observed on 01/06/25 at 9:10 am, near the door leading outside. During an interview, an LPN stated that the vomit had been present since breakfast and that housekeeping staff had been informed, but they indicated it would be cleaned later. The Director of Nursing later stated that nursing staff are expected to clean up bodily fluids such as vomit as soon as possible, with housekeeping responsible for disinfecting the area afterward. This deficiency potentially affects all 21 residents in the memory care unit, as identified by the census provided by the Administrator on 01/05/25.
Inaccurate PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessments for five residents, which is a critical process to prevent inappropriate placement in nursing homes for long-term care. The residents involved had documented diagnoses of mental health disorders, including major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar disorder, mood disorder, and post-traumatic stress disorder. Despite these diagnoses, the PASRR assessments for these residents inaccurately documented that they did not have a diagnosis or suspected mental illness. The Social Services Director acknowledged during an interview that the facility did not verify the accuracy of the PASRR Level 1 assessments for these residents before their admission. This oversight in the assessment process is likely to result in the residents not receiving the necessary services tailored to their mental health needs, as the PASRR process is designed to ensure appropriate placement and care for individuals with mental disorders or intellectual disabilities.
Inaccurate Care Plans and Implementation Failures
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for two residents, leading to potential unawareness of their actual needs by the staff. For one resident, the care plan inaccurately included a communication problem related to a hearing deficit, despite the resident having no such diagnosis. The resident's Minimum Data Set (MDS) indicated adequate hearing without the use of a hearing aid, and during an interview, the resident confirmed no hearing issues. The facility administrator acknowledged the care plan's inaccuracy, emphasizing the expectation for care plans to reflect residents' needs accurately. Another resident's care plan included interventions for wearing bilateral resting hand splints and elbow extension splints, yet there was no physician order for these splints. The resident's mother reported that the splints were not being used during her visits, despite her complaints to the facility. Observations confirmed the resident was not wearing the splints on multiple occasions. This discrepancy between the care plan and actual practice highlights a failure in implementing the prescribed interventions, potentially affecting the resident's care and comfort.
Failure to Change Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents, leading to a deficiency in the care provided. For one resident, who was dependent on supplemental oxygen and had multiple diagnoses including severe dementia and chronic kidney disease, the oxygen tubing was not changed as required. The tubing was last dated 12/22/24, and staff confirmed it should have been changed weekly, but it was not done on 12/29/24. Additionally, there was no medical order for the use of oxygen or care of the equipment for this resident. Another resident, with acute respiratory failure and COPD, also experienced a lapse in care. The oxygen tubing for this resident was not dated, despite a medical order requiring the tubing to be changed every four weeks. Staff confirmed the tubing should have been changed weekly and dated accordingly, but this was not done. These failures in changing and dating the oxygen tubing put residents at risk of becoming ill due to improper respiratory care.
Failure to Assess Bed Rail Safety Risks
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the risk of entrapment in bed rails, which is a significant safety concern. Six residents were identified as having bed rails installed without the necessary assessments, physician orders, or informed consent. Observations revealed that these residents had bilateral quarter side rails in place, yet their medical records lacked documentation of risk assessments, discussions of risks and benefits with the residents or their representatives, and consent forms. Additionally, there was no evidence that the bed dimensions were appropriate for the residents' size and weight. For Resident #23, the care plan indicated the use of bed rails for mobility and positioning, but the comprehensive Minimum Data Set (MDS) did not reflect this usage. Similarly, Resident #25's care plan did not document the use of bed rails, and the admission MDS also failed to indicate their use. Resident #55's care plan and quarterly MDS did not document the use of bed rails, and the same lack of documentation was found for Residents #65, #95, and #98. The Director of Nursing (DON) confirmed that bed rail assessments should be conducted quarterly, but there was no evidence of such assessments being completed for these residents. The absence of proper assessments and documentation for the use of bed rails poses a potential risk of serious injury due to entrapment. The facility's failure to follow protocols for assessing and documenting the use of bed rails indicates a significant oversight in ensuring resident safety. The DON acknowledged the requirement for quarterly assessments but was unable to provide evidence that these assessments had been conducted for the affected residents prior to the survey observations.
Medication Administration Error Due to Improper Handling
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a rate of 15.63%. During a medication administration observation, a registered nurse (RN) administered medications to a resident without wearing gloves or using a medication cup. The RN used his bare hands to open medication bottles and poured the pills directly into his hand before administering them to the resident. This practice was contrary to the facility's protocol, as confirmed by the Director of Nursing, who stated that staff should wear gloves and use medication cups when preparing and administering medications. The RN admitted to normally using the cap of the medication bottle and a pill cup but was unsure why he deviated from this practice during the observed incident.
Violation of Resident Dignity During Mealtime
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect by conducting medical assessments in the dining area during mealtime. This was observed in two instances involving two residents. The first resident, who has severe cognitive impairment and multiple medical conditions including type 2 diabetes, malnutrition, and severe dementia, was approached by a medical provider during lunch. The provider took the resident's vital signs in the presence of other residents and staff, interrupting his meal. In another instance, a registered nurse interrupted a second resident's breakfast to take her vital signs and administer medication in the dining room. The nurse admitted to normally performing such tasks in the privacy of residents' rooms but was in a hurry on this occasion. The Director of Nursing confirmed that medical assessments should not be conducted during mealtimes or in communal areas when others are present.
Unsanitary Food Storage in Memory Care Unit
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in the memory care unit. During an observation, a pitcher of white liquid, which was neither labeled nor dated, was found on a tray in the television room of the memory care unit. This area was accessible to residents, including two identified residents. The Nurse Aide in Training (NAIT) confirmed that the pitcher should not have been left there and speculated that it contained milk from breakfast. The facility's records indicated that breakfast was served from 7:30 am to 9:00 am, suggesting the pitcher had been left out for over an hour.
Expired Medications and Improper Storage of Completed Therapy Medications
Penalty
Summary
The facility failed to ensure that medications and medical supplies were not expired and that medications were properly destroyed after completion of therapy. During an observation and interview with the Assistant Director of Nursing (ADON) in the medication room on the Skilled Care Unit, an expired Ultrasound Gel was found on top of the refrigerator by the bladder scanner. The ADON confirmed the expiration and stated that expired medications and supplies should be removed from the medication storage room and medication carts on or before the expiration date. Additionally, the facility did not remove medications for a resident after the completion of therapy. A review of the resident's medical orders revealed an order to administer ceftriaxone with lidocaine for three days. However, two unused bottles of ceftriaxone and two bottles of lidocaine were found in the medication storage room after the order was completed. The ADON acknowledged that the medications should have been removed as soon as the order was completed, but staff failed to do so.
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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