Las Cruces Village Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 3025 Terrace Drive, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325067
- Inspections on file
- 29
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Las Cruces Village Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
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.
Two residents' care plans were not updated to reflect their current needs for fall prevention measures, such as bed positioning and fall mats, or for incontinence management with briefs, despite these interventions being in use. One resident's care plan also incorrectly listed them as an elopement risk, even though they were fully dependent and unable to leave bed. The DON confirmed that these omissions meant staff may not have been aware of the necessary care approaches.
Staff did not conduct regular rounding on multiple residents, resulting in one resident remaining on the floor for several hours after a fall and several rooms not being checked for an extended period, contrary to the facility's standard practice of rounding every two hours.
A medication cart was found unattended with insulin pen needles and lancets left on top instead of being locked inside the cart. Both an LPN and the ADON confirmed that these items should have been secured according to facility policy.
A resident with advanced Parkinson's disease, who was nonverbal and unable to use the call light, fell out of bed and remained on the floor for over three hours without staff checking on her. Video evidence confirmed that staff failed to conduct required rounds, and the resident was not discovered until the next scheduled check.
The facility did not maintain documentation showing that allegations of neglect and misappropriation of property involving two residents were thoroughly investigated. In one instance, a resident with severe cognitive impairment was left on the floor for hours after a fall, and in another, a resident reported missing money and unauthorized bank transactions. Required interviews, video reviews, and investigation records were not documented or retained.
A resident admitted with a stage 2 pressure ulcer did not have this condition or the required wound care documented in their baseline care plan within 48 hours of admission. Despite physician orders and progress notes indicating the need for pressure ulcer care, the baseline care plan omitted these details, as confirmed by the DON and the resident's family member.
A resident admitted with a stage 2 pressure ulcer did not receive timely wound care, as staff failed to obtain wound care orders for three days and did not document or perform wound care on several days following admission. The Wound Care Nurse was not available at admission, and nursing staff did not follow expected protocols for early wound management.
The facility did not provide required written discharge or transfer notifications, discharge summaries, or bed hold notices to several residents and their representatives during hospitalizations or discharges. Written notifications lacked essential information about appeal rights and Ombudsman contacts, and copies were not sent to the Ombudsman as required. Staff interviews confirmed inconsistent practices in providing and documenting these notifications.
Four residents did not have comprehensive, person-centered care plans that addressed their individual diagnoses or personal activity preferences. Two residents' care plans omitted their preferred activities, while another lacked a plan for hypertensive urgency, and a fourth did not have care plans for adrenocortical insufficiency or required bathing assistance. These deficiencies were confirmed by staff interviews and record reviews.
Staff did not notify the provider when a resident with hypertension had blood pressure and heart rate readings outside of physician-ordered parameters, despite orders to hold medication and inform the provider in such cases. The resident continued to receive isosorbide during these episodes, and the DON confirmed that provider notification did not occur as required.
Staff failed to notify the provider when a resident repeatedly refused or was not administered prescribed medications, including antihypertensive and cholesterol-lowering drugs. The provider was also not informed when medications were held due to blood pressure readings, despite the absence of specific parameters in the orders. The DON confirmed that expected communication with the provider did not occur.
A resident with multiple health conditions experienced prolonged diarrhea, which was inadequately assessed and treated by the facility. Despite frequent loose bowel movements and the use of Linzess, a medication known to cause diarrhea, the staff failed to notify the provider or adjust treatment appropriately. The resident's hydration status was not adequately monitored, leading to severe dehydration and acute kidney injury.
A facility failed to provide adequate staffing, resulting in unmet care needs for several residents. A resident requiring a Hoyer lift was not consistently toileted as ordered, while another waited up to 45 minutes for assistance due to insufficient staff. Two residents experienced significant delays in receiving assistance, with one having to eat meals in bed and another waiting hours for transfers. Staff interviews confirmed these issues, highlighting ongoing staffing challenges.
The facility failed to maintain complete and accurate medical records for two residents. One resident's nursing administration record lacked documentation of water administration through a PEG tube, despite orders. Another resident's medical record did not document their death, including the time and notifications made. Staff interviews confirmed these documentation lapses.
The facility failed to ensure staff adhered to transmission-based precautions for residents diagnosed with COVID-19. Despite the requirement for all staff and visitors to wear N95 masks, multiple staff members, including an RN, LPN, and CNA, were observed not complying with this protocol. The regional nurse consultant confirmed the mask requirement, highlighting a significant lapse in infection control measures.
A resident with Alzheimer's disease was involuntarily secluded when a CNA blocked their bedroom doorway with a bed to prevent wandering into other rooms. The facility's administrator confirmed this action was against the resident's will and acknowledged it as a deficiency.
A CMA in a LTC facility misappropriated controlled narcotics by documenting the administration of medications to three residents that were not actually given. The incident was uncovered after a colleague reported a suspicious text from the CMA, who claimed it was a joke. An investigation revealed discrepancies in medication records, and interviews with the residents confirmed they did not receive the medications as documented. The CMA was the only staff member to document the administration of these medications, leading to her termination.
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 Update Care Plans for Fall Prevention, Incontinence, and Elopement Risk
Penalty
Summary
The facility failed to revise and update the care plans for two residents following changes in their care needs and health status. For both residents, observations revealed that their beds were in the lowest position and fall mats were in place due to their high risk for falls, and both were wearing briefs due to incontinence. However, their care plans did not document the use of bed positioning, fall mats, or the use of briefs and related interventions. Additionally, one resident's care plan continued to list them as an elopement risk, despite updated assessments showing the resident was fully dependent for activities of daily living and unable to leave the bed independently. Interviews with the DON confirmed that the care plans lacked documentation of these interventions and that the care plans should have been updated to reflect the current needs and approaches for each resident. The absence of these updates meant that staff may not have been aware of the necessary interventions for fall prevention, incontinence management, and elopement risk, as the care plans did not accurately reflect the residents' current conditions and required care strategies.
Failure to Perform Regular Rounding on Residents
Penalty
Summary
Staff failed to perform regular rounding on 11 out of 19 residents in the 400 Unit, as evidenced by record review, video surveillance, and interviews. One resident fell out of bed and remained on the floor for approximately three hours without staff checking on them. Video footage confirmed that staff did not round on several rooms between 11:00 PM and 3:23 AM, affecting multiple residents. The facility's standard practice, as stated by the Administrator, is to round on residents at least every two hours, but this was not followed during the cited period.
Unsecured Medication Cart with Insulin Needles and Lancets
Penalty
Summary
A medication cart located near the 500 and 600 unit halls was observed to be left unattended with insulin pen needles and lancets placed on top of it, rather than being secured inside the locked compartments as required. This observation was made during a survey at the nurses' station, and both an LPN and the Assistant Director of Nursing confirmed that these items were not properly secured. The facility failed to ensure that all drugs and biologicals, including injection devices and lancets, were stored in locked compartments in accordance with professional standards.
Resident Left Unattended After Fall Due to Missed Staff Rounds
Penalty
Summary
Staff failed to conduct required rounds on a resident who was dependent on staff for mobility and unable to use the call light or call out for help due to advanced Parkinson's disease and nonverbal status. Video evidence showed that the resident fell out of bed and remained on the floor for over three hours without staff checking on her. The last staff entry into the resident's room occurred late in the evening, and no one re-entered until early the next morning, at which point the resident was found on the floor. The resident's medical history included Parkinson's disease with dyskinesia, repeated falls, muscle weakness, disorientation, and dependence on a wheelchair. The resident required assistance with personal care and was unable to ambulate independently. The administrator confirmed that staff are expected to conduct rounds every two hours, especially for residents unable to seek help on their own, but this standard was not met in this case.
Failure to Document Thorough Investigations of Alleged Neglect and Misappropriation
Penalty
Summary
The facility failed to provide evidence that allegations of neglect and misappropriation of property were thoroughly investigated for two residents. In the first case, a resident with severe cognitive impairment (BIMS score of 0) was reported to have fallen out of bed and remained on the floor for approximately three hours without staff rounding. The facility's incident report did not include documentation of interviews with all staff present during the incident, communication with the resident's family, or findings from a review of facility video footage. The Administrator confirmed that there was no documentation of these investigative steps, despite having viewed the video. In the second case, a resident with intact cognitive function (BIMS score of 15) reported unauthorized transactions on his bank statement and missing cash from his wallet. The grievance report was incomplete, lacking follow-up documentation. The Administrator stated that an investigation was conducted but could not provide evidence that the allegation of misappropriation of property was thoroughly investigated. The corporate nurse confirmed that administrators are expected to document all interviews and retain all investigation-related documents, which was not done in these cases.
Failure to Include Pressure Ulcer and Wound Care in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one of three residents reviewed. Specifically, a resident was admitted with a documented stage 2 pressure ulcer on the sacrum, as noted in physician orders and progress notes. The physician orders included specific wound care instructions, and the admission MDS indicated the presence of a pressure ulcer and the need for pressure ulcer care. However, the baseline care plan created for the resident did not document the existence of the pressure ulcer or the need for wound care. During interviews, the resident's family member reported that there was no plan of care in place, and the DON confirmed that the baseline care plan did not include the pressure ulcer or wound care needs. The deficiency was identified through record review and interviews, which showed that the required information for immediate care was not included in the baseline care plan as expected.
Failure to Provide Timely Wound Care for Pressure Ulcer on Admission
Penalty
Summary
A deficiency occurred when staff failed to provide timely and appropriate wound care for a resident admitted with a stage 2 pressure ulcer. Upon admission, the resident had an existing wound, but staff did not obtain wound care orders until three days later. Documentation shows that wound care was not performed or recorded on the day of admission and for several subsequent days. The Treatment Administration Record for the relevant period lacked entries indicating that wound care was provided, and there were no progress notes explaining the omission. Interviews with facility staff revealed that the Wound Care Nurse was not present at the time of admission and only assessed the resident's wound several days later. The Director of Nursing confirmed that the expectation is for nurses to obtain care orders and provide wound care within the first 48 hours of admission. However, this protocol was not followed, resulting in a lack of consistent wound management for the resident during the initial days of their stay.
Failure to Provide Required Written Discharge, Transfer, and Bed Hold Notifications
Penalty
Summary
The facility failed to provide the required written discharge or transfer information to residents and their representatives for multiple residents who were hospitalized or discharged. Specifically, there was no written notification of discharge or transfer provided in a language and manner understandable to the resident or their representative, and in some cases, no documentation of the discharge or transfer was present in the medical record. For one resident, there was no discharge summary that included a recapitulation of the stay, final clinical status, or medication reconciliation. Additionally, written notices did not include required information about appeal rights or contact information for the State Long-Term Care Ombudsman. For several residents who were transferred to the hospital, the facility did not provide written transfer notifications or bed hold notifications at the time of transfer or as soon as practicable. In some cases, the bed hold notification was completed but did not indicate who was notified, and there was no evidence that a written copy was given to the resident or their representative. Staff interviews confirmed that written notifications were not consistently provided, and that the process for notifying residents, representatives, and the Ombudsman was not followed as required. The facility also failed to send copies of the written discharge or transfer notices to the Ombudsman, instead only sending a list of residents who transferred or were discharged. Staff responsible for these notifications, including the Social Services Director and Business Office Manager, confirmed that written notifications were not always provided or documented, and that family members were sometimes only notified by phone or required to pick up written notices in person. These deficiencies were identified through record review and staff and resident interviews.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for four residents. For two residents with dementia and other behavioral or mood disorders, the care plans did not include their personal preferences for activities, such as pet visits, group activities, going outdoors, and religious services, as identified in their MDS Annual Assessments. The Activity Director confirmed that these preferences, although assessed, were not incorporated into the residents' care plans. Additionally, one resident with a primary diagnosis of hypertensive urgency did not have a care plan addressing this condition, and another resident with adrenocortical insufficiency lacked a care plan for this diagnosis as well as for the level of assistance required for showering or bathing, as indicated in the MDS assessment. The corporate nurse confirmed the absence of these care plans. These omissions were identified through record reviews and staff interviews.
Failure to Notify Provider of Abnormal Vital Signs as Ordered
Penalty
Summary
Facility staff failed to notify the provider of abnormal vital signs for a resident with a diagnosis of essential hypertension. Physician orders specified that isosorbide should be held and the medical doctor notified if the resident's systolic blood pressure was less than 100 or greater than 150, or if the pulse was less than 50. Despite this, staff documented several instances where the resident's blood pressure exceeded 150 and the pulse dropped below 50, but there was no evidence that the provider was notified as required by the order. Review of the medication administration record showed that the resident continued to receive isosorbide daily during periods when vital signs were outside the specified parameters. The Director of Nursing confirmed that staff did not contact the physician or provider to report the elevated blood pressure and low heart rate, contrary to the physician's instructions. The expectation was for staff to notify the provider as directed in the order, but this did not occur.
Failure to Notify Provider of Medication Refusals and Held Doses
Penalty
Summary
The facility failed to meet professional standards of practice for medication management for one of three residents reviewed. Specifically, staff did not notify the physician or provider when a resident repeatedly refused prescribed medications, including atorvastatin and carvedilol, or when medications were held due to blood pressure readings. Documentation showed that the resident refused atorvastatin on multiple occasions across two months and that carvedilol was either refused or held several times, sometimes due to blood pressure readings. However, there were no documented notifications to the physician or provider regarding these refusals or the holding of medications. Additionally, the order for carvedilol did not include parameters for when the medication should be held based on blood pressure readings, yet staff held the medication for various blood pressure values without provider guidance. The Director of Nursing confirmed that staff did not contact the physician or provider about the resident's medication refusals or about concerns regarding blood pressure readings, despite the expectation that such communication should occur. The resident involved had diagnoses including cerebrovascular disease, essential hypertension, and hyperlipidemia.
Failure to Adequately Assess and Treat Prolonged Diarrhea
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically in the assessment and treatment of prolonged diarrhea. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, unspecified dementia, delirium, dysphagia, and gastrostomy status, experienced persistent diarrhea. Despite documentation of frequent loose bowel movements, the facility did not adequately assess the cause or provide appropriate treatment. The resident's medical records revealed that they were receiving Linzess, a medication known to cause diarrhea, without a corresponding diagnosis of irritable bowel syndrome or chronic constipation. Additionally, the resident was prescribed Imodium A-D to treat diarrhea, which is contradictory to the effects of Linzess. The nursing staff failed to document notifying the provider about the resident's ongoing diarrhea after the initial report on November 19, 2024, and did not question the concurrent use of Linzess and Imodium A-D. Furthermore, the facility did not take timely action to assess the resident's hydration status, despite signs of dehydration indicated by elevated sodium and chloride levels in lab results. The resident's hydration was solely dependent on PEG tube administration, and the staff did not request additional fluids to compensate for the fluid loss due to diarrhea. This oversight contributed to the resident's severe dehydration and acute kidney injury, as diagnosed during a hospital visit following a fall.
Staffing Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of several residents, leading to unmet care requirements. Resident #1, who requires assistance with a Hoyer lift and two staff members for toileting, was not consistently assisted as per physician's orders. Documentation revealed missed toileting sessions, and staff interviews confirmed the inability to ensure the resident was toileted three times daily due to staffing shortages. Resident #3 reported waiting up to 45 minutes for assistance in or out of bed, as the facility lacked enough staff to meet the needs of residents requiring two-person assistance with Hoyer lifts. On one occasion, only one CNA was available for the entire housing unit, which included several residents needing significant assistance. This shortage led to delays and unmet care needs, as confirmed by staff interviews. Resident #4 and Resident #5 also experienced significant delays in receiving assistance due to staffing shortages. Resident #4, who requires a sit-to-stand device, had to eat meals in bed instead of the dining room, which she preferred for social interaction. Resident #5, who also requires a Hoyer lift, reported waiting over an hour for assistance and sometimes up to three hours to be transferred to bed after lunch. Staff interviews corroborated these accounts, highlighting the facility's ongoing staffing challenges.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, which could potentially impact the care provided. For one resident, the nursing administration record did not document the administration of 135 mL of water through a PEG tube on multiple occasions, despite physician orders. Interviews with staff revealed that feeding pumps were programmed to administer feedings and water flushes automatically, but documentation was still required. The Director of Nursing confirmed that staff did not document several water boluses as expected. For another resident, the facility's medical record lacked documentation regarding the resident's death. Although the hospice nurse's progress note indicated the resident had passed and notifications were made, the facility's records did not reflect this information. The Assistant Director of Nursing confirmed the absence of documentation about the resident's death, including the time of death and notifications made to the family and provider.
Failure to Adhere to COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention measures by not ensuring that staff adhered to transmission-based precautions for residents diagnosed with COVID-19. During an interview, the front desk staff confirmed that the facility had residents diagnosed with COVID-19 and that all staff and visitors were required to wear N95 masks. However, observations revealed multiple instances of non-compliance. An RN in the Alzheimer unit was observed not wearing an N95 mask while at the nurse's station. Similarly, an LPN in the East unit was seen wearing a surgical mask that did not cover her nose and stated she was not informed about the mask requirements. Further observations showed that a CNA in the hallway near the nurse's station was wearing a surgical mask, and the wound care nurse had to remind her of the N95 mask requirement. Additionally, an LPN in the [NAME] unit was observed sitting at the nurse's station without a mask. The regional nurse consultant confirmed that all facility staff were required to wear N95 masks in nursing units and patient care areas when there was a resident diagnosed with COVID-19. These lapses in following the infection control program could potentially lead to the spread of infections among the 67 residents in the facility.
Involuntary Seclusion of Resident Due to Wandering
Penalty
Summary
The facility failed to protect a resident from involuntary seclusion, which is defined as the separation of a resident from other residents or confinement to their room against their will. This incident involved a resident diagnosed with Alzheimer's disease, insomnia, and hypertension. On a specific date, the resident's bedroom doorway was blocked by the bed while the resident was inside, preventing them from moving freely throughout the unit. This action was taken by a CNA during the day shift because the resident was wandering around the unit and entering other residents' rooms. The incident was confirmed by the facility's administrator, who acknowledged that the staff should not confine residents to their rooms against their will. The nurse assigned to the resident on the day of the incident was informed by the DON about the blocked doorway, but by the time she checked, the doorway was no longer obstructed. The administrator confirmed that the resident was involuntarily secluded by the facility staff, which constitutes a deficiency in the care provided to the resident.
Misappropriation of Residents' Medications by CMA
Penalty
Summary
The facility failed to prevent the misappropriation of residents' medications, specifically controlled narcotics, by a Certified Medication Aide (CMA). The incident involved three residents who were documented as having received medications that they did not actually receive. CMA #8 documented that a resident received a PRN oxycodone, another received a PRN hydrocodone, and a third received two alprazolam tablets, when in fact, these medications were not administered as recorded. The discrepancies were discovered during an investigation initiated after CMA #9 reported a text from CMA #8, in which she asked for residents' medications for personal use, claiming it was a joke. The investigation revealed that CMA #8 was the only staff member to document the administration of the controlled narcotics to the three residents on the specified date. Interviews with the residents confirmed that they did not recall receiving the medications as documented. One resident, who was moderately impaired, did not remember receiving Percocet for a headache, while another, who was cognitively intact, stated she did not request or take hydrocodone, preferring Tylenol instead. The third resident, also cognitively intact, confirmed receiving only one alprazolam tablet instead of two. The facility's investigation and police report corroborated these findings, leading to the termination of CMA #8.
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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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