Ladera Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 5901 Ouray Road Nw, Albuquerque, New Mexico 87120
- CMS Provider Number
- 325037
- Inspections on file
- 32
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 44
Citation history
Health deficiencies cited at Ladera Center during CMS and state inspections, most recent first.
The facility failed to follow and obtain physician orders for several residents, including providing O2 and a wrist brace without orders, missing multiple weekly Mounjaro injections due to pharmacy and pre-authorization issues without timely follow-up, and serving hot beverages in a regular cup instead of a prescribed sippy cup. Additional residents had care plans calling for built-up utensils or scoop plates, but there were no corresponding physician orders for these adaptive eating devices, despite the OT indicating that long-term use requires an order. These actions and omissions demonstrate a pattern of not ensuring that treatments, medications, and adaptive equipment were supported and implemented according to physician orders.
Surveyors found that staff failed to maintain sanitary conditions in two shower rooms. In one shower room, brown fecal matter remained on the floor, shower chair, and shower curtain, with a strong, offensive odor present, and the EVSR confirmed it should have been cleaned immediately after use but was not. In another shower room, a used facility gown was left next to an uncovered clean towel rack instead of being placed in a soiled clothing container, and the EVSR acknowledged that the towel rack should have been covered and the gown properly handled to prevent cross contamination.
The facility failed to promptly address and resolve multiple resident grievances related to missing personal items, smoking practices, and an allegation of neglect. A family-reported missing TV was not investigated or communicated back by staff, and several residents reported missing clothing that was neither found nor replaced, with no follow-up provided. Grievance logs showed that missing-item complaints were left unacted upon for extended periods, and a department head admitted not responding to about two months of grievances due to short staffing. Residents also reported that smoking times were reduced without discussion at resident council and that repeated complaints about smoking had gone unanswered. Additionally, a family grievance alleging that a resident was left overnight in day clothes and shoes after a CNA failed to return was not followed up by the SSA, who had written the grievance but did not ensure a response or family communication.
Surveyors found that two residents were transferred to the hospital—one for abnormal labs, cancer treatment, PEG tube feeding needs, bedbound status, and COVID positivity, and another for behavioral symptoms including agitation and psychosis—without required written transfer notices, appeal rights information, or bed-hold notifications being provided to them or their representatives, and without written notice being sent to the Ombudsman. Record reviews showed no transfer or bed-hold documentation in either medical record, and the SSD acknowledged she had not been notifying the Ombudsman of discharges and saw no nursing notes regarding transfers, discharges, or bed-hold notices. The DON stated she was unaware that nursing was responsible for the transfer and bed-hold notice process, despite expecting that nursing and the business office would send these notices within 24 hours.
The facility failed to create complete baseline care plans within 48 hours of admission for three residents, omitting essential information needed for immediate care. One resident with a right forearm fracture and mobility issues did not have use of a wrist brace or oxygen documented in the baseline care plan. Another resident with cerebral palsy and chronic idiopathic constipation had a physician order for daily Lactulose, but constipation and related care needs were not included in the care plan. A third resident admitted with hip and wrist fractures and a surgical hip wound had a baseline care plan that addressed ADL assistance, diabetes, fall risk, pain, psychotropic drug risk, and skin breakdown, but did not include wound care for the surgical hip site.
The facility failed to revise care plans and include required IDT members. One resident with post‑stroke deficits developed bilateral hand contractures that were not added to the care plan with corresponding goals or interventions. Another resident with chronic idiopathic constipation and a physician order for daily lactulose had no care plan problem, goal, or intervention addressing constipation or related care needs. In addition, for a separate resident, the documented care plan conference included the resident, family, nursing, rehab, and social services, but did not include the CNA or the provider, and the SSD reported not knowing that these disciplines were required to attend.
Surveyors found that two residents who depended on staff for ADL assistance had long, dirty fingernails with dark material under the nail beds over multiple observations. One resident with a healing arm fracture, muscle weakness, and gait abnormalities reported that no one had addressed his nails since admission, and staff confirmed his nails were long and dirty. Another resident with post-stroke hemiplegia, aphasia, and dysphagia was observed on several occasions with similarly unkempt nails, despite having recently received a shower when nail care should have been provided. CNAs, a CMA, and the Unit Manager acknowledged that nail care is expected on shower days and as needed, but confirmed that it did not occur for these residents.
Surveyors found that a treatment cart containing prescription topical ointments, powders, and wound cleaning supplies was left unlocked and unattended, contrary to facility expectations confirmed by the DON. A treatment cart on another station contained two opened suture removal kits that an LPN acknowledged should have been discarded but were not. In addition, an expired insulin pen was discovered in a medication cart, and an LPN confirmed it was past its discard date and should have been removed but remained in storage.
Staff failed to follow infection prevention and control practices when a CNA assisted two residents with meals, using bare hands to handle each resident’s spoon and food in sequence without performing hand hygiene between contacts, then returning to the first resident and continuing assistance without hand hygiene. In an interview, the DON confirmed that hand hygiene was not performed between resident care, contrary to expectations. The facility also lacked an effective surveillance system to identify environmental hazards before they could spread to residents and staff.
Two residents were observed in bed without accessible call light buttons, with one call light hanging near the floor beside the bed and another draped over a headboard. In each case, the resident could not reach the device used to summon assistance, and both an LPN and a CNA confirmed that the call lights were not within reach despite acknowledging they must be accessible at all times.
A resident with multiple comorbidities, including a right femur fracture, DM2, SLE, osteoporosis, dementia, and generalized muscle weakness, developed an in-house acquired unstageable pressure injury to the coccyx. Nursing notes and weekly skin assessments documented the presence of this unstageable pressure injury, as well as an unstageable sacral wound, and family was present for wound care and teaching. However, the corresponding MDS assessment indicated there were no unhealed pressure ulcers or injuries, and the MDS Coordinator confirmed that the assessment did not accurately reflect the resident’s documented coccyx pressure injury.
A resident at risk for skin breakdown did not receive a Braden Scale assessment on admission as required by facility policy, and turning/repositioning interventions were not added to the care plan until later despite multiple risk factors including decreased activity, impaired cognition, limited mobility, incontinence, and recent hip surgery. Braden assessments were only documented on later dates, and there was no documented off-loading of the coccyx. These failures in timely risk assessment and off-loading contributed to tissue necrosis and the development of a coccyx pressure injury, as confirmed by the ADON during interview.
A resident who required assistance with dressing due to limited arm use was put to bed fully clothed with shoes on, despite a care plan stating it was important for her to follow her preferred routines and choose her clothing, including pajamas at night. The resident later reported that an aide had promised to return to change her but did not, and she remained in daytime clothes and shoes overnight. The resident’s family raised concerns, and multiple staff, including the ADON, SSA, and a CNA, acknowledged that the situation was inappropriate and not consistent with the resident’s documented preferences.
A resident with hemiplegia, HTN, depression, and type 1 DM had documented activity preferences on the MDS and in the care plan, including listening to music, pet visits, group activities, and religious services, but the facility failed to provide and document these individualized activities. Record review showed no Recreation Participation Record or progress notes reflecting that the preferred activities occurred. The AD reported the resident does not speak and is in isolation, and described expectations that staff log participation and provide group and 1:1 activities. The RAD stated the resident was placed on 1:1 programs at admission and acknowledged that the activities program was not very solid over several months, despite expectations that staff conduct 1:1 activity programs with the resident.
A resident with Parkinson’s disease and visual impairments was served a lunch tray that included green peas, despite the meal ticket and dietary profile clearly indicating a preference for no sides of peas or spinach. The resident ate about half of the peas served. An LPN assisting with the meal and the Dietary Manager both confirmed that the resident’s stated preference excluded peas and that this preference was not followed during the meal service.
Surveyors found that the facility did not consistently follow safe food storage and handling practices, potentially affecting all 107 residents. During a kitchen observation, a box of frozen hamburger patties was found stored in the freezer left open to the air, and the Dietary Manager acknowledged it should not have been left open. In a separate observation, a dietary aide with facial hair was serving lunch without a beard guard, and the Dietary Manager confirmed that a beard guard should have been worn.
Insufficient staffing resulted in missed or delayed showers, inadequate eating assistance, and poor grooming for multiple residents. Staff reported being unable to complete all required tasks, and several residents confirmed they did not receive scheduled showers or timely help with meals. The use of undignified language by staff and observations of uncut, dirty fingernails further demonstrated the impact of staffing shortages on resident care and dignity.
The facility did not serve meals at the posted times, with lunch, breakfast, and dinner consistently delayed. A resident reported that meals often arrived late, and a CNA confirmed that residents were upset by the unpredictability. Observations showed lunch trays were served in the dining room and delivered to resident rooms well after the scheduled time, and the Dietary Manager stated that meal plating began at the posted time, causing further delays.
Two residents submitted grievances regarding missing items and roommate concerns, but the facility did not document investigations, outcomes, or provide written resolutions as required by policy. Staff interviews revealed that concerns were often handled informally and not always treated as formal grievances, resulting in residents not being informed of the results of their complaints.
A resident dependent on staff for ADL care did not receive regular showers, eating assistance, skin assessments, or grooming as required by their physician-approved plan of care. Staff interviews and documentation revealed missed showers, infrequent nail care, and inadequate application of prescribed medicated creams due to staffing shortages and time constraints. The resident was observed with poor hygiene, worsening skin conditions, and insufficient assistance during meals, with staff and management confirming these deficiencies.
Two residents with significant medical needs did not receive scheduled assistance with bathing and showering, as required by their care plans. Documentation and interviews revealed that showers were frequently missed, with both residents and staff confirming the lack of regular hygiene care. Family and clinical staff reported concerns about poor hygiene and neglect, and administrative staff were unable to provide complete records or oversight of the shower documentation process.
Three residents with complex medical conditions did not have written, signed, and dated progress notes from their primary care providers after required visits. Review of their medical records showed no documentation of provider visits or care, and the DON confirmed the absence of such records, resulting in incomplete documentation of physician oversight.
A resident with complex medical needs experienced a change in condition, including fever and cough, but did not receive timely care due to delayed responses from the primary care service. Despite repeated attempts by nursing staff and the resident's family to contact the provider and requests for hospital transfer, necessary orders and interventions were significantly delayed, resulting in prolonged discomfort and a worsening condition.
A resident with a recent cervical laminectomy experienced frequent severe pain, often rated between 7 and 9 out of 10, despite having multiple pain medications ordered. Staff and leadership were aware of the ongoing high pain levels and the resident's complaints, including a formal grievance about inadequate and untimely pain relief, but failed to escalate or adjust pain management appropriately.
A resident with a history of myocardial infarction reported chest pain, but the LPN did not notify the medical provider, as the resident appeared stable during assessment. The resident's significant cardiovascular history was not considered, and the resident was later found without signs of life. The failure to notify the provider likely contributed to the resident's passing.
A resident with a history of myocardial infarction reported chest pain, but the LPN did not conduct a thorough assessment or notify a doctor. The resident was found deceased shortly after. Staff interviews indicated that chest pains should be taken seriously, especially for residents with significant cardiovascular history.
The facility failed to maintain sanitary conditions during meal service, with staff improperly handling cups and bowls by the rims and not performing hand hygiene. An activity staff member, an unknown female staff, and a CNA were observed handling food and beverages inappropriately, which were then consumed by residents. The Dietary Manager confirmed that proper handling practices were expected but not followed.
The facility failed to provide meals that were palatable and served at the correct temperature, affecting several residents. A resident's POA reported meals were often cold and unrecognizable, leading to the resident not eating. Another resident stated the food was often at the wrong temperature and tasted bad. Observations showed delays in meal service, with meals served later than the posted time and a test tray revealing unappealing and flavorless food. The Dietary Manager acknowledged past complaints and attributed delays to short staffing.
A resident with multiple health issues, including atrial fibrillation and hypertension, did not have a comprehensive care plan addressing cardiovascular risks. The omission was discovered after the resident experienced chest pain and subsequently passed away. The care plan was updated posthumously to include necessary cardiovascular risk information.
A resident with significant medical needs, including amputation and legal blindness, was not provided with necessary assistance for toileting. Staff instructed the resident to use the restroom in his brief instead of assisting him to the toilet, despite his care plan requiring dependent assistance. The resident expressed dissatisfaction with this practice, and the DON confirmed it was unacceptable.
A resident with a documented banana allergy received banana-flavored yogurt and an actual banana, despite her allergy being noted on her meal ticket. This oversight occurred on multiple occasions, raising concerns about adherence to dietary orders. The resident's medical records confirmed her allergy to bananas, erythromycin, and Keflex.
The facility failed to provide adequate staffing for the safe operation of a Hoyer lift, affecting two residents. Despite care plans requiring a two-person assist, staff shortages led to improper use, causing discomfort and injury. Interviews revealed that CNAs often operated the lift alone due to insufficient staff availability, a situation acknowledged by the DON.
The facility failed to provide a homelike environment for two residents by not ensuring the hallway remained free of a persistent urine smell. Observations and interviews confirmed the smell was a constant issue, particularly on weekends, causing discomfort and disgust. A housekeeper acknowledged the issue, attributing it to resident rooms and stating that rooms were cleaned once daily and as requested with an odor-removing spray, but the smell persisted.
The facility failed to provide an activities program that met the interests and preferences of three residents. Assessments lacked lists of preferred activities, scheduled activities were inconsistently conducted, and the facility did not allow transportation for community outings. The sole Activities Assistant was unable to manage all activities or update the schedule, leading to resident dissatisfaction.
The facility failed to monitor blood sugar levels and notify the physician when a resident's blood sugar dropped below 70 mg/dL. This affected two residents with type 2 diabetes mellitus, leading to multiple instances of undocumented blood sugar readings and unreported low blood sugar levels. The Unit Manager acknowledged that staff did not follow the hypoglycemia protocol, particularly during a holiday weekend.
Failure to Follow and Obtain Physician Orders for Treatments, Medications, and Adaptive Devices
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards by not following or obtaining physician orders for multiple residents. One resident with a right wrist fracture and respiratory illness was observed sitting in a wheelchair with a right wrist brace and receiving O2 at 2 L/min via nasal cannula. Record review showed there were no physician orders for either the oxygen therapy or the wrist brace. The DON confirmed that the resident had a wrist brace and was receiving oxygen without corresponding orders in the electronic medical record and stated that nurses should have addressed this and obtained provider orders, but this did not occur. Another resident with type 2 DM, morbid obesity, and long-term use of insulin and injectable non-insulin antidiabetic drugs had multiple sequential orders for weekly Mounjaro injections. Review of the MAR showed missed Mounjaro doses on three specific dates. The resident reported that the facility was not consistently administering the weekly injection and that some weeks the medication was not available and the dose was skipped. The ADON confirmed the missed doses, explaining that the medication was not available on two of the dates due to pharmacy/insurance pre-authorization issues, and that on another date the medication arrived several days late and the resident refused it because it was too close to the next scheduled dose; the ADON stated nurses should have requested the medication from the pharmacy as soon as they knew it was not available, but this did not happen. A resident with hemiplegia, vascular dementia with behavioral disturbance, aphasia, and dysphagia had a dietary order for a scoop plate and a sippy cup for hot beverages. During a meal observation, this resident was served hot coffee in a regular cup despite the meal slip indicating a sippy cup for hot beverages. The admissions coordinator confirmed that the hot coffee was served in a regular cup and acknowledged that, per the dietary order, all hot beverages should have been served in a sippy cup, which did not occur. Additional deficiencies involved adaptive eating devices and the lack of corresponding physician orders. One resident with multiple sclerosis, type 2 DM, generalized muscle weakness, and a right rotator cuff tear had a care plan specifying built-up utensils for all meals, but record review did not show a physician order for built-up utensils. Another resident with Alzheimer’s disease, vascular dementia, psychophysiologic insomnia, and hearing loss had a care plan for rehab eating devices, including a scoop plate during meals, but there was no physician order for a scoop plate. A further resident with a left hand contracture, orthostatic hypotension, restless legs syndrome, and a neurostimulator had a care plan for built-up utensils for all meals, yet no physician order for built-up utensils was found. In interviews, the OT stated that he evaluates residents for built-up utensils, notifies the dietitian and dietary so the devices are placed on meal tickets, and that if a resident needs built-up utensils for a long period of time, a physician order is needed, which was not present in these cases.
Failure to Maintain Sanitary Shower Rooms and Proper Linen Separation
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe, clean, and sanitary environment when fecal matter was observed remaining in a common shower area and when soiled and clean linens were not properly separated. During observation of the south shower room, brown fecal matter was present on the floor, the shower chair, and the shower curtain, accompanied by a strong, offensive odor upon entry. In an interview immediately following this observation, the environmental services regional manager (EVSR) confirmed the presence of fecal matter on these surfaces and acknowledged that this was unsanitary and should have been addressed as soon as staff completed assisting a resident in the shower room, but it had not been done. In a separate observation of the north shower room, a used facility gown was found placed next to an uncovered clean towel rack. The EVSR confirmed that the used gown should have been placed in the soiled clothing container as soon as possible and that the clean towel rack should have been covered, but neither of these practices had occurred.
Failure to Promptly Address Resident Grievances on Missing Items, Smoking, and Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to promptly respond to and resolve resident grievances, particularly regarding missing personal items, smoking concerns, and an allegation of neglect. A family member reported that a television purchased for a resident and brought to the facility went missing after the Maintenance Director removed it to address cable connection issues and replaced it with a facility-owned TV. The Social Service Assistant acknowledged receiving an email from the family about the missing TV but did not complete a grievance report or follow up, and the Maintenance Director confirmed the TV disappeared and that he did not notify the family. Multiple residents reported missing personal clothing, stated they had filed grievances, and indicated that their items had neither been found nor replaced, and that they had not received any response to their grievances. Record review of grievances over specific dates showed that missing personal item grievances had not been acted upon. The Social Services Director stated that grievance follow-up should occur within seven days, but the Administrator explained that there was no response documented on the grievance forms because the grievances had not been resolved and the facility was still looking for the items. The Laundry Director reported that she had not responded to approximately two months of grievances due to short staffing and lack of time to review them. Resident council minutes and interviews revealed ongoing concerns about smoking schedules and the reduction in the number of smoke breaks, with one resident stating that the Administrator had changed smoking times and frequency without discussing it with residents at council and that repeated concerns about smoking had not received a response. A grievance form documented a family member’s concern that a resident had been put to bed in the afternoon and left in day clothing and shoes all night after a CNA failed to return to change the resident into night clothes. The Social Services Assistant stated she wrote this grievance during a care conference and handed it to nursing but did not follow up on the response or on communication with the family, and later acknowledged she should have followed up since she initiated the grievance. The Administrator reported that he had spoken with a resident about volunteering to supervise smokers and about safe-smoker testing and communication equipment, but he did not document these discussions, and the resident reported that months had passed without further contact or resolution. Overall, the report documents that grievances, including those alleging neglect, were not promptly investigated, followed up, or communicated back to residents and families.
Failure to Provide Required Written Transfer, Appeal, and Bed-Hold Notices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required written transfer, discharge, appeal rights, and bed-hold notifications to residents and their representatives, and to notify the Ombudsman, for residents who were transferred to the hospital. The facility’s Transfer and Discharge policy dated 06/11/25 required complete documentation, physician involvement, written notice to residents and/or representatives in a language and manner they understand, information on appeal rights, and notification of the Ombudsman. For one resident, admitted on an unspecified date, progress notes showed he was sent to the hospital on a specified date due to abnormal lab values, cancer treatment, PEG tube feeding, being bedbound, and a positive COVID test. However, his medical record contained no documented transfer notice or bed-hold notification related to this hospital transfer. For a second resident, admitted on an unspecified date, progress notes documented that he was sent to the hospital due to behavioral symptoms including agitation and psychosis, and later transferred to a psychiatric hospital after a hospital psychiatrist determined he was not safe to return. Review of this resident’s medical record likewise showed no documented transfer notice or bed-hold notification for the hospital transfer. In interviews, the Social Service Director stated there were no notes in the first resident’s record explaining why he did not return, acknowledged she did not contact the Ombudsman regarding his discharge, and confirmed there were no nurses’ notes regarding transfer, discharge, or bed-hold notices for either resident. She also stated she has not notified the Ombudsman of discharges in a while. The DON stated she did not realize nursing was responsible for the transfer and bed-hold notice process, although her expectation was that nurses and the business office send out transfer, discharge, and bed-hold notices within 24 hours.
Failure to Develop Complete Baseline Care Plans on Admission
Penalty
Summary
The facility failed to develop accurate baseline care plans within 48 hours of admission for three residents, omitting key information necessary for their immediate care. For one resident admitted with a nondisplaced fracture of the right ulna, muscle weakness, and gait and mobility abnormalities, record review showed that the baseline care plan dated 12/27/25 did not include the resident’s use of a right wrist brace or oxygen, despite these needs being present. In an interview, the DON confirmed the baseline care plan date and acknowledged that the use of the wrist brace and oxygen were omitted from the baseline care plan. Another resident admitted with chronic idiopathic constipation, a personal history of digestive system disease, and cerebral palsy had a physician’s order for daily Lactulose for constipation, but the baseline care plan dated 01/20/26 did not address the chronic idiopathic constipation or related care and support needs. The UM confirmed that this omission did not meet her expectations. A third resident admitted with a displaced intertrochanteric fracture of the left femur, a displaced comminuted fracture of the left radius, difficulty walking, and age-related osteoporosis had a baseline care plan dated 01/02/26 that addressed ADL assistance, diabetes, fall risk, pain, psychotropic drug risk, and skin breakdown risk, but did not address wound care for a surgical hip wound present on admission. The UM confirmed the resident arrived with a surgical hip wound and that wound care should have been included in the baseline care plan but was not.
Failure to Revise Care Plans and Include Required IDT Members
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and complete person‑centered care plans based on residents’ current conditions and to ensure required Interdisciplinary Team (IDT) participation in care plan meetings. For one resident with a history of hemiplegia, hemiparesis, aphasia, and dysphagia following a cerebral infarction, record review showed that the care plan last updated on 12/29/25 did not include any goals or interventions addressing newly developed bilateral hand contractures or the support needed for this condition. During interview, the Unit Manager confirmed that this resident’s care plan did not meet her expectations because it omitted the bilateral hand contractures and related care and support needs. For another resident admitted with chronic idiopathic constipation, a personal history of other digestive system diseases, and cerebral palsy, physician orders dated 01/10/26 included lactulose to be given daily for constipation, but the care plan dated 01/20/26 did not address chronic idiopathic constipation or related care and support. The Unit Manager confirmed this omission during interview. In addition, review of a third resident’s Care Plan Conference form showed that the documented attendees included the resident, the resident’s representative, a nurse, rehab, and the Social Services Director, but did not include the resident’s CNA or physician. In interview, the Social Services Director stated that the IDT meetings included rehab, a nurse, and the director of social services, and that the provider and CNA were not included because she did not know they had to be in attendance.
Failure to Provide Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary activities of daily living (ADL) care, specifically nail care, to two residents who were dependent on staff for this assistance. One resident was admitted with diagnoses including a nondisplaced fracture of the right ulna styloid process, generalized muscle weakness, and abnormalities of gait and mobility. During an observation in the resident’s room with his daughter, surveyors noted that his fingernails on both hands were long with a dark brown substance under the nail beds. The resident stated that no one had addressed his fingernails since his admission. A CNA confirmed that the resident’s fingernails were long and dirty and stated that nail care is done regularly but “it did not happen.” The second resident was admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, and dysphagia following cerebral infarction. On three separate observations, this resident’s fingernails on both hands were repeatedly noted to be long with a dark brown substance under the nail beds, including when the resident appeared to be sleeping in bed. Multiple staff interviews confirmed that the resident’s fingernails were long and dirty. One CNA reported that the resident had received a shower the previous day and that the fingernails should have been addressed but were not. A CMA and the Unit Manager also confirmed that the resident’s fingernails remained long and dirty, and the Unit Manager stated that CNAs are expected to provide nail care on shower days and as needed, but this did not occur.
Improper Storage and Handling of Medications and Medical Supplies
Penalty
Summary
Surveyors identified a deficiency related to improper storage and handling of medications and medical supplies. During an observation of the south station at 8:06 a.m., a treatment cart containing prescription topical ointments, powders, and wound cleaning supplies was found unlocked and unattended. In a subsequent interview, the DON confirmed that the cart had been left unlocked and unattended and stated that all treatment carts were expected to be locked, which did not occur. Additional observations showed that the north station treatment cart contained two opened suture removal kits in the top drawer, and an LPN confirmed that the kits were open and should have been discarded appropriately, which had not happened. Surveyors also found an insulin pen with a past discard date in the south front medication cart, and another LPN confirmed that the insulin pen was expired and should have been discarded appropriately, which also had not occurred. These findings demonstrate failures to properly secure treatment carts, prevent use of opened medical supplies, and remove expired insulin from active medication storage.
Failure to Follow Hand Hygiene Protocols During Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow an ongoing infection prevention and control program, specifically related to hand hygiene during meal assistance and environmental surveillance. During an observation in the dining room on 01/27/26 at 12:40 pm, CNA #3 assisted two residents, R #20 and R #42, who were seated at the same table. CNA #3 used her bare right hand to touch R #20’s spoon, scooped a spoonful of food, placed the spoon in R #20’s right hand, and instructed R #20 to eat. Without performing hand hygiene, CNA #3 then turned to R #42, picked up R #42’s spoon with her bare hands, scooped a spoonful of food, placed the spoon in R #42’s hand, and instructed R #42 to eat, before returning to R #20 and continuing assistance without any hand hygiene. In an interview at 12:46 pm, the DON confirmed that CNA #3 did not perform hand hygiene between helping the residents during the meal and stated that hand hygiene should be performed between resident care. The report also notes that the facility lacked a system of surveillance to identify environmental hazards before they could spread to residents and staff, and references related findings under F0584.
Inaccessible Call Light Systems for Bedbound Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the resident call system was accessible to residents who were in bed. During an observation on 01/20/26 at 4:18 pm, one resident (R #8) was found in bed with the call light button hanging on the side of the bed and nearly touching the floor, out of the resident’s reach. The resident stated she uses the call light button to call for help but did not know where her call light button had gone. In a subsequent interview at 4:20 pm, an LPN confirmed that the call light button was on the side of the bed and not within the resident’s reach, and acknowledged that call light buttons are required to be within reach at all times and that this had not occurred. On 01/21/26 at 9:44 am, another resident (R #41) was observed in bed with the call light button draped over the headboard, also not within reach. In an interview at 4:21 pm, a CNA confirmed that the call light button was draped over the headboard and not accessible to the resident, and similarly stated that call light buttons must be within reach at all times and that this requirement had not been met.
Inaccurate MDS Assessment for Resident With Unstageable Pressure Injury
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident by not documenting an existing unstageable pressure injury. The resident was admitted with multiple diagnoses, including an intracapsular right femur fracture, type 2 diabetes mellitus, systemic lupus erythematosus, age-related osteoporosis, unspecified dementia without behavioral disturbance, and generalized muscle weakness. Nursing progress notes documented ongoing skin checks, including right hip and right lower extremity assessments, and on one date a new in-house acquired unstageable pressure wound to the coccyx was identified. Subsequent nursing documentation noted family presence for wound care and teaching related to this unstageable coccyx pressure injury. Weekly skin assessments for the resident showed that on one date there was no pressure injury, but later entries documented an unstageable pressure injury to the sacrum due to slough and then an unstageable in-house acquired pressure injury to the coccyx area. Despite these documented findings in the clinical record, the MDS assessment for the resident, dated within the same time frame, indicated in section M0210 that there were no unhealed pressure ulcers or injuries. During an interview, the MDS Coordinator confirmed that this MDS assessment did not accurately reflect the resident’s unstageable coccyx pressure injury.
Failure to Complete Admission Braden Assessment and Off-Loading Leading to Coccyx Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for pressure ulcer prevention for one resident identified as being at risk for skin breakdown. Record review showed that the facility’s Braden Scale policy required completion of a Braden assessment on resident move-in, but no Braden Scale assessment was completed on this resident’s admission date. Subsequent Braden assessments were documented only on 04/01/23, 04/08/23, and 04/14/23. The resident’s care plan, dated 04/28/23, identified the resident as being at risk for skin breakdown related to decreased activity, impaired cognition, limited mobility, poor safety awareness, incontinence, shear or friction, informed refusals of care, and recent right hip surgery noted on 03/28/23. The care plan intervention for turning and repositioning every 1 to 2 hours was not added until 04/01/23, despite the identified risk factors. The report also notes a lack of documented off-loading of the coccyx area, which directly contributed to tissue necrosis and the development of a pressure injury to the coccyx. During an interview, the ADON confirmed that Braden Scale assessments are supposed to be done on admission and acknowledged that this did not occur for this resident.
Failure to Honor Resident’s Nighttime Clothing Preferences and Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity and allowed to exercise her preferences regarding nighttime clothing. The resident’s sister reported that the resident had been put to bed fully clothed and with her shoes on, contrary to the resident’s preference to wear pajamas at night. The resident’s care plan, dated 10/02/24, documented that it was important for the resident to engage in meaningful daily routines relative to her preferences, including choosing what clothing to wear. Despite this, the resident was put to bed without being changed into her preferred bed clothing and with her shoes left on. Facility staff interviews confirmed awareness of the incident and that the care provided did not align with the resident’s preferences or care plan. The ADON acknowledged familiarity with the incident and stated that staff should have changed the resident into her preferred clothing and removed her shoes. The Social Services Assistant reported that the family raised concerns at a care conference, stating the resident was unhappy about being left fully clothed with shoes on. A CNA stated that when she arrived the morning after the incident, the resident was upset and reported that an aide had put her to bed, said she would return to change her, and never came back. The CNA confirmed the resident was still in her daytime clothing and shoes, noted that the resident needed assistance with changing due to inability to use her arm, and admitted she did not report the incident to facility staff.
Failure to Provide Individualized Activities Based on Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing program of individualized activities based on a resident’s documented interests and care plan. One resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, essential hypertension, unspecified depression, and type 1 DM with hyperglycemia. The admission MDS documented the resident’s personal activity preferences, including listening to music, pet visits, group activities, and religious services. A care plan revision later included these personal preferences, but staff did not follow the care plan to provide these preferred activities. Record review showed no Recreation Participation Record documenting that the resident received pet visits, music, or religious services, and there were no progress notes indicating individual participation in activities. During interview, the AD stated the resident does not speak and is now in isolation, and that sensory items would be offered. The AD reported that his expectation is for activity assistants to log participation and progress notes and provide group and 1:1 activities. The RAD stated the resident was placed on 1:1 programs upon admission and that activities staff were now focusing on 1:1 programs, but also acknowledged that the activities program was not very solid during a several-month period, and that the expectation was for staff to conduct 1:1 activity programs with this resident.
Failure to Honor Resident Dietary Preference for No Peas
Penalty
Summary
The facility failed to honor a resident’s documented food preferences when a meal including green peas was served despite the resident’s dietary profile specifying no sides of peas or spinach. The resident, who had diagnoses including Parkinson’s disease with dyskinesia, presence of an intraocular lens, and presbyopia, was observed in the dining room receiving a lunch tray containing beef chili corn chip casserole, a flour tortilla, green peas, grapes, and hot coffee. The meal ticket for this resident clearly stated that no sides of peas or spinach should be provided, yet the tray included green peas, and the resident consumed about half of the peas served. During interviews, the LPN assisting with the meal and the Dietary Manager both confirmed that the resident’s preference was to receive no peas or spinach with meals and acknowledged that this preference was not followed at this lunch service.
Improper Food Storage and Lack of Beard Guards in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in the facility’s food service operations related to food storage and staff use of protective equipment. On 01/20/26 at 12:13 p.m., observation of the kitchen revealed a ten‑pound box of frozen hamburger patties stored in the freezer left open to the air. During an interview at 12:15 p.m. the same day, the Dietary Manager confirmed that the box of frozen hamburgers was open to air and acknowledged it should not have been left open. The report notes that these practices are likely to affect all 107 residents listed on the census provided by the Administrator on 05/12/25 and may lead to foodborne illnesses in residents if proper food storage and safe food handling practices are not adhered to. On 01/27/26 at 12:27 p.m., a subsequent kitchen observation showed a Dietary Aide serving lunch without wearing a beard guard. In an interview at 12:38 p.m., the Dietary Manager confirmed that the Dietary Aide was not wearing a beard guard and stated that he should have been. These findings demonstrate failures to ensure stored foods are not left open to air and to ensure staff with facial hair wear appropriate beard nets in the kitchen.
Insufficient Staffing Leads to Missed Care and Compromised Dignity
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 110 residents, resulting in missed or delayed care in several key areas. Certified Nursing Assistants (CNAs) reported being unable to complete all required tasks during their shifts, including providing scheduled baths or showers, assisting with transfers that require two staff members, and offering adequate eating assistance to residents who require help with activities of daily living (ADLs). Multiple residents confirmed that they did not receive showers as frequently as scheduled or desired, with some reporting only one or two showers per month instead of the expected two or three per week. Residents also reported long wait times for call lights to be answered and expressed frustration and dissatisfaction with the lack of assistance. Observations during meal times revealed that residents who required substantial or maximal eating assistance were not always helped in a timely manner. Some residents were left to attempt eating on their own, resulting in soiled clothing and incomplete meals, while staff confirmed that there were not enough personnel to assist all residents who needed help during meals. The use of the term "feeders" by staff to refer to residents needing eating assistance was observed and confirmed as common practice, raising concerns about the maintenance of resident dignity. Additionally, residents dependent on the facility for ADLs were observed with uncut and dirty fingernails on multiple occasions, indicating a lack of regular grooming and personal hygiene care. Interviews with staff and residents consistently pointed to inadequate staffing levels as the primary reason for these deficiencies, with staff stating they were "stretched too thin" and unable to provide the level of care required. Facility leadership acknowledged challenges with staffing and documentation but did not provide evidence of effective measures to address the shortfalls at the time of the survey.
Failure to Serve Meals at Posted Times Disrupts Resident Dining Experience
Penalty
Summary
The facility failed to serve meals to residents at the posted serving times for breakfast, lunch, and dinner. Observations and interviews revealed that lunch, which was scheduled for 12:30 pm, was consistently served late, with the first tray being served in the dining room at 12:51 pm and the last at 1:11 pm on one day, and similar delays observed on the following day. Trays delivered to resident rooms in the north and south halls were also delayed, with the first trays not arriving until well after the posted lunch time. The Dietary Manager confirmed that the kitchen begins plating food at the posted time rather than having meals ready to serve, resulting in further delays. Residents and staff reported ongoing issues with meal timeliness. One resident stated that all meals, including breakfast and dinner, are always late, sometimes with breakfast arriving as late as 9:00 am and lunch and dinner being served significantly after the scheduled times. A CNA confirmed that residents become upset due to the unpredictability of meal delivery. These consistent delays in meal service disrupted the residents' dining experience as meals were not provided at the times posted by the facility.
Failure to Investigate and Resolve Resident Grievances per Policy
Penalty
Summary
The facility failed to conduct thorough investigations and provide appropriate resolutions for grievances submitted by two residents. According to the facility's grievance policy, all concerns and grievances must be investigated, documented, and followed up on, with written resolutions provided to the residents. However, review of grievance forms for two residents showed that the forms lacked documentation of investigations, outcomes, or notifications to the residents regarding the resolution of their grievances. One resident reported missing personal items and concerns about her roommate, but there was no evidence of investigation or communication of results. Another resident submitted a grievance, but the form did not indicate whether it was investigated or resolved, nor if the resident was informed of the outcome. Interviews with staff revealed that concerns voiced by residents were often handled informally and not always documented as formal grievances. The Social Services Director acknowledged that she did not always treat resident concerns as formal grievances and did not consistently investigate or resolve them. The LPN and DON both indicated that residents were encouraged to fill out their own grievance forms, and staff would only assist if the resident was unable to do so. The Administrator confirmed that if residents chose not to fill out a grievance form, staff would attempt to resolve the issue informally, rather than following the formal grievance process. Both residents involved were cognitively intact, as indicated by their BIMS scores, and were able to clearly recall events and express their concerns. Despite this, they reported not receiving any feedback or resolution regarding their grievances. The facility's grievance logs showed that grievances were being submitted and investigated, but the specific grievances for these two residents lacked documentation of investigation, outcome, or communication, indicating a failure to follow the facility's established grievance policy.
Failure to Provide Required ADL, Skin, and Grooming Care
Penalty
Summary
The facility failed to provide essential Activities of Daily Living (ADL) care, including showers, eating assistance, skin assessments, and grooming, for one resident who was dependent on staff for these services as outlined in the physician-approved plan of care. Documentation and interviews revealed that the resident required substantial to maximal assistance with bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Despite these needs, staff interviews confirmed that showers, grooming, and nail care were frequently missed due to staffing shortages and time constraints. Observations and interviews with the resident and family further confirmed infrequent bathing, lack of assistance with eating, and inadequate application of prescribed medicated creams for skin conditions. Medical records and staff statements indicated that physician orders for weekly skin checks and daily application of medicated creams were not consistently followed. Gaps in skin assessment documentation were noted, and the resident was observed to have worsening skin conditions, including redness, wounds, and flaking, as well as a foul odor and unclean appearance. The nurse practitioner and family members reported that the resident's skin condition deteriorated due to missed showers and lack of proper skin care, and that the resident was often found soiled and in dirty clothing. The nurse practitioner also noted that the resident required extensive assistance with eating due to physical limitations, but was observed not receiving adequate help during meals. Grooming deficiencies were also documented, with observations of long, dirty fingernails and confirmation from staff that nail care was not performed regularly. The DON and nurse manager acknowledged that staff were responsible for these tasks and that documentation and care were not provided as required by the resident's plan of care. The cumulative effect of these failures resulted in the resident not receiving care in accordance with professional standards and physician orders.
Failure to Provide Scheduled ADL Assistance for Bathing and Showering
Penalty
Summary
Facility staff failed to provide scheduled assistance with activities of daily living (ADLs), specifically bathing and showering, for two residents who were dependent on staff for personal care. Both residents had complex medical conditions, including epilepsy, multiple sclerosis, hemiplegia, dementia, and other diagnoses that required substantial or maximal assistance for ADLs such as bathing, grooming, dressing, and toileting. Care plans for both residents specified the need for regular showers multiple times per week, but documentation and interviews revealed that these scheduled showers were frequently missed. Review of shower tracking logs showed significant gaps in care, with one resident receiving only 2 to 5 showers out of 12 or 13 scheduled opportunities per month, and the other receiving 2 to 4 showers in similar periods. Both residents reported not receiving showers as scheduled, with one expressing feelings of depression and the other describing discomfort and frustration due to prolonged periods in soiled briefs. Family members and a nurse practitioner also reported concerns, including poor hygiene, skin issues, and evidence of neglect, such as a strong odor, dirty clothing, and untrimmed fingernails. The nurse practitioner reported the situation to the state health department after observing these conditions during a clinic visit. Interviews with CNAs confirmed that showers were regularly missed, often due to low staffing. The administrator was unable to provide additional shower records and was unfamiliar with the documentation process, while the DON confirmed that no other records were available and that CNAs were expected to chart showers in the tracking software. A newly hired LPN stated she had not received instructions on cosigning shower logs. The ombudsman also noted that missed showers were a common concern among residents during a routine visit.
Lack of Physician Progress Notes and Documentation After Required Visits
Penalty
Summary
The facility failed to ensure that residents had written, signed, and dated progress notes from their physicians after each required visit. Record reviews for three residents with significant medical conditions, including cerebral infarction, dysphagia, epilepsy, dementia, hemiplegia, hemiparesis, and Parkinson's disease, revealed that their electronic medical records did not contain any documentation of visits or care provided by their primary care service (PCS) providers. The face sheets for these residents indicated that their primary care providers were medical doctors from a local PCS not associated with the facility. Further review of the electronic medical records for the specified periods showed no evidence of PCS provider visits or care for any of the three residents. During an interview, the Director of Nursing confirmed that the medical records for these residents lacked documentation from the PCS providers regarding medical care or visits. This resulted in incomplete resident records and a lack of documented physician review and oversight for the affected residents.
Delayed Provider Response and Care for Change in Resident Condition
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dysphagia, and epilepsy experienced a change in condition, including chills, a low-grade fever, and a cough. The nursing staff contacted the resident's primary care service (PCS) multiple times to report the change and request further orders, but there were significant delays in receiving responses and new orders. The resident's daughter requested immediate hospital transfer, but staff informed her that PCS approval was required, and both staff and the daughter experienced prolonged periods without a response from the PCS. During this time, the resident's symptoms persisted, and care was not provided in a timely manner according to the resident's needs and preferences. Documentation shows that orders for additional treatments, such as nebulization, were not received until days after the initial change in condition was reported. Interviews with staff and the Director of Nursing confirmed that the delay in provider response affected the resident's care. The lack of timely intervention and communication with the provider likely resulted in the resident experiencing unnecessary discomfort and a worsening of her condition.
Failure to Provide Effective Pain Management
Penalty
Summary
Facility staff failed to provide effective pain management for a resident who had recently undergone a cervical laminectomy and was experiencing frequent, severe pain. Despite multiple physician orders for pain medications, including acetaminophen, lidocaine cream, oxycodone, and Excedrin, the resident reported ongoing pain, often rating it between 7 and 9 out of 10 on the pain scale. Nursing progress notes and pain assessments documented repeated high pain scores, and the resident expressed dissatisfaction with the adequacy and timeliness of pain relief, including filing a formal grievance regarding these concerns. The facility's response to the grievance was limited to noting that pain medication was scheduled by the physician, with no additional interventions documented. Interviews with nursing staff and facility leadership confirmed awareness of the resident's frequent severe pain and the inadequacy of pain management. Staff acknowledged that pain levels above 5 or 6 should prompt further intervention, and both the unit manager and DON stated that the resident's pain should have been addressed sooner. The resident also reported that requests for pain medication were sometimes unmet, leading to frustration and feelings of neglect. The deficiency was further substantiated by the lack of timely escalation or adjustment of pain management strategies despite ongoing high pain scores and the resident's repeated complaints.
Failure to Notify Provider of Chest Pain in Resident with Cardiovascular History
Penalty
Summary
The facility failed to notify the medical provider of a change in condition for a resident with a history of myocardial infarction who reported chest pain. The resident, identified as R #112, had a significant medical history including diabetes mellitus, sepsis, acute respiratory failure, atrial fibrillation, myocardial infarction type 2, hypertension, and congestive heart failure. Despite these conditions, when the resident reported chest pain to a CNA, the nurse on duty, LPN #1, assessed the resident but did not notify the medical provider because the resident appeared to be at his baseline condition during the assessment. The resident's vital signs were recorded, and although the resident was pale and had cool skin, there was no active complaint of chest pain at the time of the nurse's assessment. LPN #1 did not inquire further about the nature of the chest pain, such as its type, duration, or frequency, and did not consider the resident's cardiovascular history in her decision-making process. This lack of action was contrary to the expectations of the Certified Nurse Practitioner, who stated that any report of chest pain should be taken seriously, especially for residents with significant cardiovascular history. Subsequently, the resident was found without signs of life, and despite attempts at resuscitation, the efforts were unsuccessful. The failure to notify the medical provider of the resident's chest pain likely contributed to the resident's passing. Interviews with other staff members, including another LPN, confirmed that the protocol should have involved notifying the provider and potentially sending the resident to the emergency room for further evaluation.
Failure to Properly Assess Chest Pain in Resident with Cardiovascular History
Penalty
Summary
The facility failed to provide quality care to a resident with a history of myocardial infarction when they did not properly assess the resident after he reported chest pains. The resident, who had a significant cardiovascular history including atrial fibrillation, heart failure, and hypertension, reported chest pain to a CNA. The CNA notified an LPN, who assessed the resident and took vital signs but did not inquire further about the chest pain or notify a doctor. The LPN did not consider the resident's cardiovascular history during the assessment. The resident's vital signs were recorded, but the assessment lacked detailed information about the chest pain, such as its type, duration, and frequency. The LPN confirmed that she did not notify the doctor of the resident's chest pain and could not recall considering the resident's cardiovascular history. The resident was found deceased approximately 45 to 60 minutes after reporting chest pain, and CPR was initiated but ultimately unsuccessful. Interviews with other staff members, including a CNP and another LPN, indicated that chest pains should always be taken seriously, especially for residents with significant cardiovascular history. The staff should have notified the provider and considered sending the resident to the emergency room for further evaluation. The failure to properly assess and respond to the resident's chest pain likely contributed to the resident's passing.
Improper Food Handling During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during meal service, as observed on multiple occasions. During a lunch meal service, an activity staff member was seen handling residents' cups and bowls by the rims without performing hand hygiene between serving trays. This improper handling was observed as residents consumed the food and beverages served. Additionally, an unknown female staff member was observed handling bowls of food with her thumb touching the inside rim, which was also consumed by residents. Further observations revealed a Certified Nursing Aide (CNA) handling a bowl of vegetables with her thumb inside the bowl and delivering it to a resident. The CNA continued to handle glasses and bowls by the rims, with her thumb on the inside, while serving meals to other residents. The Dietary Manager later stated that the expectation was for all staff, including dietary staff, to follow proper handling and serving practices, which were not adhered to in these instances.
Deficient Meal Service and Quality
Penalty
Summary
The facility failed to ensure that meals were served in a palatable and attractive manner, affecting the quality of life for several residents. Resident #10's Power of Attorney reported that meals were often delivered last and cold, leading to the resident not eating due to the food being unrecognizable and tasting horrible. Resident #10 confirmed that meals were frequently cold and sometimes forgotten altogether. Resident #52 stated that the food was often at the wrong temperature and tasted bad about half the time. Resident #54 reported that meals were always served late and cold, and an observation confirmed that lunch had not been served to this resident by 1:12 pm. Observations of meal service revealed delays in serving meals, with beverages being served before meals and the last meal tray being served significantly later than the posted meal time of 12:30 pm. A test tray observation showed that the meal was unappealing and flavorless, with a hamburger that was unseasoned and no salt or pepper provided. The Dietary Manager acknowledged receiving complaints about the food being cold and unpalatable when he started two months ago, attributing delays to short staffing, although he noted improvements with full staffing. However, the issues persisted during the survey period.
Failure to Include Cardiovascular Risks in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for a resident, identified as R #112, which included critical medical history and cardiovascular risk factors. The resident was admitted with multiple diagnoses, including diabetes mellitus, sepsis, acute respiratory failure, atrial fibrillation, myocardial infarction type 2, hypertension, and congestive heart failure. Despite these significant health issues, the care plan did not initially address the resident's cardiovascular risks or provide guidance on recognizing and responding to cardiovascular emergencies. The deficiency was highlighted when the resident experienced chest pain, as reported by a CNA, and was later found without signs of life. Although CPR was initiated, it was unsuccessful, and the resident passed away. A review of the care plan revealed that it lacked essential information regarding the resident's cardiovascular history and the necessary steps for staff to take in the event of a cardiovascular incident. This omission was only rectified after the resident's death, following an audit that prompted the inclusion of cardiovascular risk information in the care plan.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to maintain the ability of a resident to perform activities of daily living (ADLs) due to inadequate assistance with toileting needs. The resident, identified as R #10, was instructed by staff to use the restroom in his brief instead of being assisted to the toilet. This occurred despite the resident's need for total staff assistance with a mechanical lift due to his medical conditions, which include orthopedic aftercare following surgical amputation, morbid obesity, and legal blindness. The care plan for R #10 indicated that he required dependent assistance from one to two staff members for toileting, yet this was not provided. During an interview, the resident expressed dissatisfaction with being told to have a bowel movement in his brief and reported that this situation had occurred on several occasions. The Director of Nursing confirmed that it was not acceptable for staff to instruct residents who are not incontinent to use their briefs for bowel movements. The failure to provide necessary assistance could lead to a decline in the resident's ability to perform ADLs and cause feelings of embarrassment and indignity.
Failure to Follow Dietary Orders for Resident with Banana Allergy
Penalty
Summary
The facility failed to adhere to dietary orders concerning food allergies for a resident with a documented banana allergy. During an interview, the resident reported receiving strawberry banana yogurt on two occasions and an actual banana with her meal on another occasion, despite her allergy being noted on her meal ticket. The resident expressed concern about the potential danger due to her banana allergy, which is documented in her medical records. A review of the resident's facesheet and diet order confirmed the allergy to bananas, alongside allergies to erythromycin and Keflex, highlighting a lapse in following dietary protocols for residents with food allergies.
Inadequate Staffing for Hoyer Lift Operation
Penalty
Summary
The facility failed to ensure adequate staffing for the operation of a Hoyer lift, a mechanical device used for transferring patients, which affected two out of three residents reviewed for Hoyer lift usage. Specifically, the facility did not provide enough staff to operate the lift safely, resulting in instances where only one staff member was available to assist with transfers, contrary to the care plan requirements. This deficiency was highlighted by a complaint from a family member of a resident who reported that staff were too rough during transfers, leading to bruising. The resident's care plan required a two-person assist with a licensed nurse's observation during transfers, but this was not consistently followed. Interviews with residents and staff revealed that the lack of sufficient staff often led to improper use of the Hoyer lift. One resident expressed trust in only a few CNAs who understood how to operate the lift correctly, while others caused discomfort and injury. Another resident confirmed that CNAs sometimes operated the lift alone. Staff interviews corroborated these accounts, with CNAs admitting to using the lift by themselves due to staffing shortages. The Director of Nursing acknowledged the issue, noting that while staff were trained on proper lift usage, it was challenging to have more than one person available due to other duties such as showers and medication passes.
Persistent Urine Smell in Hallway
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for two residents by not ensuring the hallway remained free of a persistent urine smell. On multiple occasions, surveyors observed a strong smell of urine in the facility's north hallway near the nurse's station. Interviews with a resident and a family member confirmed that the smell was a constant issue, particularly on weekends, causing discomfort and disgust. A housekeeper acknowledged awareness of the issue, attributing the smell to resident rooms and stating that rooms were cleaned once daily and as requested with an odor-removing spray, but the smell persisted.
Failure to Provide Adequate Activities Program
Penalty
Summary
The facility failed to provide an activities program designed to meet the interests and preferences of each resident for three residents reviewed for activities. Resident #4's Recreation Comprehensive Assessment did not include a list of his preferred activities, and he was unaware of the schedule for group activities due to inconsistent delivery of the monthly event calendar and a blank whiteboard in the day room. Resident #5's assessment also lacked a list of preferred activities, and a scheduled activity did not occur because the Activities Assistant (AA) had to go to the store. Resident #5 expressed disappointment and concern about the lack of activities, especially on weekends. Resident #6's assessment similarly did not include his preferred activities, and he expressed a desire for more group activities, outdoor time, and community trips, which were not provided by the facility. The AA confirmed that she was the only activities staff member since the beginning of the month and was unable to conduct all scheduled activities or update the whiteboard. She also mentioned that the facility did not allow the use of transportation vehicles for resident outings, and weekend activities were limited to religious services on Sundays.
Failure to Monitor Blood Sugar and Notify Physician
Penalty
Summary
The facility failed to monitor blood sugar levels and notify the physician when a resident's blood sugar dropped below 70 mg/dL. This deficiency affected two residents who were reviewed for diabetic management. One resident, admitted with type 2 diabetes mellitus, had multiple instances where blood sugar readings were not documented, and the physician was not notified of dangerously low blood sugar levels. The resident's husband filed a grievance, which revealed that the facility did not monitor the resident's blood sugar from the time of admission until several days later, despite having orders to do so. The resident's blood sugar was found to be very low on multiple occasions, but staff failed to document these readings or notify the physician as required by the hypoglycemia protocol. Another resident with type 2 diabetes mellitus also experienced low blood sugar readings that were not properly managed. The resident's blood sugar dropped below 70 mg/dL on two separate occasions, but staff did not recheck the blood sugar 15 minutes later or notify the physician, as required by the hypoglycemia protocol. The Unit Manager acknowledged that staff did not follow the protocol and failed to ensure accurate and timely blood sugar monitoring. The Unit Manager stated that the resident was admitted during a holiday weekend, which contributed to the lack of proper monitoring and documentation. The facility's failure to monitor blood sugar levels and notify the physician of low readings could result in residents feeling physically ill and unsatisfied with the care received. The report highlights significant lapses in diabetic management and adherence to medical protocols within the facility.
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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