Rio Rancho Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Rancho, New Mexico.
- Location
- 4210 Sabana Grande Se, Rio Rancho, New Mexico 87124
- CMS Provider Number
- 325033
- Inspections on file
- 32
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Rio Rancho Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete psychotherapeutic medication disclosure/consent forms for four residents before administering multiple psychotropic drugs, including antipsychotics, sedatives, antidepressants, and anxiolytics for conditions such as dementia with behavioral disturbance, MDD, anxiety, panic disorder, and psychosis. Record reviews showed that medications like Lorazepam, Seroquel, Clonazepam, Haldol, Hydroxyzine, Ramelteon, Risperidone, Mirtazapine, Caplyta, and Olanzapine were ordered and given without corresponding signed consent forms in the EHR. In an interview, the DON acknowledged that these residents should have had completed and signed consents and stated her expectation that residents or their representatives be informed about treatments and medications, including risks and benefits, before use.
Surveyors found that a computer on a cart left unattended in a hallway between two rooms displayed PHI for 15 residents, including names and room numbers, where anyone passing by could see it. The DON acknowledged that the computer should not have been left unattended with PHI visible because unauthorized individuals could easily access the information, and the Administrator confirmed that it should not have been left unattended and that nursing staff are expected to safeguard resident records.
Staff left a computer cart with a drink, a chair, and a backpack unattended in the doorway of a room, blocking entry, and separately left another unattended computer cart and chair with personal belongings in a hallway between two rooms, obstructing access to handrails and room entrances. No staff were present near these items. In an interview, the ADM stated that leaving computer carts, drinks, purses, bags, or other personal items in hallways or in front of doorways was not acceptable and that such items should be stored in designated staff areas.
Surveyors found that the facility failed to complete and submit accurate final discharge MDS assessments for two residents who were discharged to the hospital and did not return. In both cases, the discharge MDSs incorrectly indicated a status of return anticipated, and no subsequent final discharge MDSs reflecting return not anticipated were completed, despite documentation in the EHR that the residents did not come back. The DON acknowledged that MDS assessments are expected to accurately reflect residents’ current status because inaccuracies can affect billing and census, and confirmed that these two discharge assessments were inaccurate.
Surveyors found that food and beverages in the north and south nutrition room refrigerators were not consistently labeled, dated, or discarded when expired. Observations showed unlabeled pitchers of beverages, unlabeled pudding cups, and multiple pre-packaged sandwiches, nutritional supplement shakes, and fruit containers stored past their labeled dates. Facility policy required all snacks to be labeled with resident name, current date, and use-by date, and for pantries to be stocked only with covered, labeled, and dated items. The DM reported that Dietary Aides were responsible for checking and removing expired snacks three times daily, and the Administrator stated her expectation that residents not receive expired foods and acknowledged that consuming expired foods could cause illness.
The facility failed to ensure call lights were kept within reach for three residents, resulting in multiple instances where call lights were found on the floor behind or under beds while residents were in bed and needing staff access. A CNA confirmed that call lights are expected to be within reach at all times and acknowledged that the call lights for these residents were not accessible, and the unit manager stated staff are responsible for ensuring call lights remain within residents’ reach.
A resident with failure to thrive died in the facility, and afterward the resident’s daughter discovered multiple unauthorized charges on the resident’s debit card at various retail and food establishments. Bank records showed the transactions began on the day of the resident’s death. The daughter filed a police report and, upon review of video surveillance, it was confirmed that a facility employee used the resident’s debit card without authorization. The ADM acknowledged that the employee’s use of the card after the resident’s death should not have occurred.
A resident with chronic systolic CHF and COPD was repeatedly provided O2 via nasal cannula without any corresponding physician order documented in the EHR. Nursing notes showed multiple instances of O2 administration, and surveyors observed an O2 concentrator with nasal cannula and a portable O2 tank in the room. The resident reported using O2 when experiencing shortness of breath. The UM and Administrator both acknowledged that residents requiring supplemental O2 should have valid physician orders and confirmed that no such order existed for this resident, meaning O2 was administered outside of professional standards of care.
A resident with chronic thrombocytopenia and a femur fracture had a standing order for daily Eltrombopag Olamine 50 mg, including instructions to reorder when only 10 tablets remained, yet the drug was not administered on multiple documented date ranges because it was not in stock or available at the facility. Nursing notes repeatedly cited waiting on delivery or lack of stock, and the resident reported not receiving the medication for several days on multiple occasions. The UM and RN acknowledged that several doses were missed due to the medication not arriving, and the MD stated he was aware of intermittent failures to administer the drug, attributing them to inconsistent ordering processes and delays from a specialty pharmacy, despite facility policy requiring medications to be administered as ordered.
Staff did not consistently use required gowns and gloves during high-contact care activities for a resident with multiple open wounds, despite facility policy mandating enhanced barrier precautions to prevent MDRO transmission. Observations and staff interviews confirmed that PPE use was inconsistent, particularly when residents were agitated or not on isolation precautions.
A resident with a history of brain hemorrhage, hemiplegia, and high fall risk was admitted without a complete baseline care plan addressing essential needs such as fall prevention, ADL assistance, and care interventions. Despite clear risk factors and family concerns, the care plan only included personal interests and omitted critical clinical and safety measures. The resident experienced a fall resulting in ER transfer, and staff interviews confirmed the required care plan was not completed within 48 hours of admission.
The facility failed to honor the preferences of four residents regarding bathing routines and bed positioning. One resident preferred showers but received only bed baths, while another wanted more frequent bathing than provided. A third resident, who preferred bed baths for safety reasons, received fewer than expected. Additionally, a resident's preference to keep his bed in a high position was overridden by a new, undocumented facility practice aimed at fall prevention, causing him distress.
The facility failed to update care plans for several residents, omitting critical information such as hospice care, dialysis, dietary needs, and oxygen use. These omissions could lead to staff being unaware of residents' care needs.
The facility failed to ensure pharmacist recommendations for medication reviews were acknowledged by providers for three residents. Recommendations for medication modifications and monitoring were not documented as reviewed or signed by providers, indicating a lack of follow-through in medication management.
Two residents received medications late, resulting in a 45.45% error rate. One resident received Methacarbamal late, while another received 14 medications late, including those for blood pressure and muscle spasms. The CMAs confirmed the delays, citing staffing issues as a cause.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. Three CNAs did not complete the necessary training hours despite working multiple shifts. The Nurse Educator and DON confirmed the deficiency.
A resident's PHI was compromised when a CMA left a computer screen open and a narcotic book visible, exposing sensitive information to unauthorized individuals. An LPN confirmed the breach, noting that the computer screen and narcotic record should not have been left accessible to unauthorized residents, visitors, and staff.
A resident reported that a night shift CNA was hateful and restricted his use of the call light. The incident was reported to a UM but was not documented or investigated, as the UM, LPN, DON, and ADM were unaware of the allegation. This failure to report and investigate indicates a breakdown in protocol, potentially risking resident safety.
The facility failed to ensure proper discharge planning for two residents, leading to significant deficiencies in their care. One resident was discharged without necessary home health services due to a lack of communication and follow-up, while another was discharged without proper notice or intervention for behavioral issues. These failures resulted in residents being discharged without the support and care they required.
A resident received hospice services without the necessary physician orders. The care plan indicated the start of hospice care, but a review showed no physician orders were present. The DON confirmed the oversight, stating orders should have been obtained before starting hospice care.
A resident with significant impairments following a stroke developed a wound due to inadequate care in a LTC facility. The resident was not repositioned or had her brief changed frequently enough, leading to moisture accumulation and skin breakdown. Family members reported finding her in a soiled brief, and the Wound Care Nurse confirmed the wound resulted from insufficient care.
A resident with a history of repeated falls and an amputated leg was not provided with a fall mat as required by their care plan. Despite having a beveled mattress, the absence of a fall mat was confirmed by the DON, posing a risk of greater injury from falls.
A facility failed to maintain a filled portable oxygen tank for a resident with COPD, who reported the tank leaked and was unusable. Despite notifying staff, no action was taken. A CMA and RN confirmed the tank was empty, acknowledging it should be full and ready for use.
The facility failed to properly store and administer medications, as observed when five loose pills were found in a medication cart and a narcotic was signed out but not administered to a resident. A CMA confirmed the discrepancies, and the DON stated that such practices are considered medication errors.
A resident reported that meals were often cold when delivered to his room. An observation confirmed that the lunch meal temperatures were below the appropriate serving temperature, with the tamale, black beans, and coleslaw measured at 117, 110, and 112 degrees Fahrenheit, respectively. The Dietary Manager and DC acknowledged that these temperatures were not at the correct level.
A resident expressed dissatisfaction with being served cold eggs for breakfast, which they disliked. An observation confirmed the resident was served eggs, which they left uneaten. The resident's meal ticket did not indicate their dislike for eggs, and the Dietary Manager was unaware of this preference.
A facility failed to maintain complete medical records for a resident, as their EMR lacked a required Pre-Admission Screening and Resident Review (PASRR). This omission was confirmed by the DON, highlighting a deficiency in record-keeping that could affect the provision of comprehensive care.
A facility failed to collaborate with hospice services for a resident on hospice care, as no coordinated plan of care was developed. The resident's MDS indicated hospice care, but there was no hospice communication documentation in the medical record. The DON-IT noted the absence of a hospice binder, which should have been available to staff, and the DON confirmed the lack of necessary documentation.
A resident with multiple health conditions, including dementia and respiratory failure, did not receive scheduled showers for a month, with only one documented refusal. The facility's records showed inconsistencies, such as marking showers as 'not applicable' or failing to document them, indicating a breakdown in ensuring necessary care was provided.
A facility failed to ensure the accuracy of the MDS for a resident, leading to discrepancies in documentation regarding the presence of an indwelling catheter. The resident was admitted with a history of urinary issues but was inaccurately recorded as having a catheter in the MDS. Nursing notes indicated the resident requested a catheter, but scans showed no retention. The DON confirmed the MDS was incorrect, as the resident did not have a catheter upon admission.
The facility failed to deliver meals according to the scheduled times, with significant delays observed during lunch service. Two residents experienced late meal deliveries, and one reported receiving an empty plate on occasion. Interviews with the DON and dietary staff confirmed that meal delivery delays were common due to kitchen backups and forgotten trays.
The facility did not have a Registered Nurse (RN) on duty for at least 8 hours each day, as required, due to a shortage of nurses. This issue was identified through a review of staffing schedules from April to July 2024, revealing multiple days without RN coverage. The Scheduling Manager and Administrator were aware of the problem, which potentially affects all 114 residents by risking inadequate service provision.
A facility failed to maintain accurate weights for a resident with multiple diagnoses, including severe protein-calorie malnutrition. The resident was supposed to be weighed weekly for four weeks and then monthly, but only one weight was recorded. Interviews revealed confusion about who was responsible for weighing residents, leading to a deficiency in meeting professional standards of quality.
Failure to Obtain Psychotropic Medication Consents for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to obtain and complete psychotropic medication consent forms for multiple residents before initiating or continuing psychotropic medications. For one resident with senile degeneration of the brain, severe vascular dementia with behavioral disturbance, sequelae of cerebral infarction, adult failure to thrive, and generalized muscle weakness, physician orders included multiple Lorazepam and Seroquel regimens for anxiety and agitation over several dates. Review of this resident’s electronic health record on 04/27/26 showed that a Psychotherapeutic Medication Administration Disclosure/Consent form had not been completed prior to the use of Lorazepam or Seroquel. Another resident, admitted with dementia with behavior disturbance, anxiety disorder, moderate cognitive communication deficit, and mild cognitive impairment, had numerous psychotropic and related medications ordered, including several Clonazepam regimens, Haldol Decanoate IM, Haloperidol, Hydroxyzine, Ramelteon, and Risperidone for anxiety, agitation, combativeness, and insomnia. Record review on 04/27/26 revealed that no Psychotherapeutic Medication Administration Disclosure/Consent form was completed before the use of any of these medications. A third resident with Parkinsonism, dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder, and hallucinations had orders for Caplyta and Mirtazapine for major depressive disorder, with changes and discontinuations over time. The electronic health record review showed that a psychotherapeutic consent form was not completed prior to the use of Mirtazapine or Caplyta. A fourth resident, admitted with depression and panic disorder, had physician orders for Clonazepam for anxiety and Olanzapine for psychosis. Review of this resident’s electronic health record on 04/27/26 also showed that a Psychotherapeutic Medication Administration Disclosure/Consent form was not completed before these medications were used. During an interview on 04/27/26 at 2:33 p.m., the DON stated that these residents should have had completed and signed consent forms for any psychotropic medications and that her expectation is that all residents or their representatives receive information on all treatments and medications prior to use so they are aware of the risks and benefits.
Unattended Computer Cart Exposed Resident PHI
Penalty
Summary
Surveyors identified a deficiency in safeguarding residents’ personal and medical records when a computer on a cart was left unattended on the 100 unit between rooms 138 and 140, displaying protected health information (PHI) for 15 residents, including their names and room numbers, in a location visible to anyone walking by. This situation was observed on the 100 unit, where unauthorized people had the ability to access the clinical record information displayed on the screen. During interviews, the DON acknowledged that the computer should not have been left unattended with resident PHI present because unauthorized individuals could easily access the information, and the Administrator similarly stated that the computer should not have been left unattended with PHI visible and that it was her expectation that nursing staff understand the importance of safeguarding resident records. The report states that if residents’ clinical information is not sufficiently safeguarded, residents’ PHI is likely to be viewed by unauthorized residents, visitors, and staff.
Unattended Equipment and Personal Items Blocking Doorway and Handrails
Penalty
Summary
Facility staff failed to maintain an environment free from accident hazards on the 100-unit by leaving equipment and personal items unattended in resident care areas and hallways. During observation, a computer cart with a cup of coffee and a chair with a backpack were stationed in the doorway of a resident room, blocking the entrance, with no staff present nearby. In a separate observation on the same unit, an unattended computer cart and chair with staff belongings were left in the hallway between two resident rooms, obstructing access to the unit handrails, again without staff present. In an interview, the Administrator stated it was not acceptable for staff to leave computer carts unattended in front of resident doorways or to leave drinks, purses, bags, or other personal items in the hallways, and confirmed her expectation that staff store personal belongings in designated spaces, acknowledging that residents could pick up items or trip on carts and chairs blocking handrails and room access. No specific resident medical histories or conditions were described in relation to these observations.
Failure to Complete Accurate Final Discharge MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete and submit accurate comprehensive Minimum Data Set (MDS) discharge assessments for two residents who were discharged to the hospital and did not return. For the first resident, the face sheet showed an admission date of 09/16/24 and a discharge date of 02/24/26. The discharge MDS, dated with a specific discharge date, documented the resident as discharged to the hospital with a status of return anticipated. However, review of the resident’s Electronic Health Record (EHR) as of 04/27/26 showed the resident did not return to the facility, and a final discharge MDS with a status of return not anticipated was not completed or submitted as required. For the second resident, the face sheet showed an admission date of 02/24/26 and a discharge date of 03/14/26. The discharge MDS, dated with a specific discharge date, also documented a discharge to the hospital with a status of return anticipated. EHR review as of 04/27/26 revealed this resident likewise did not return to the facility, and a final discharge MDS reflecting a return not anticipated status was not completed or submitted. During an interview on 04/27/26 at 2:33 pm, the DON stated that her expectation was for MDS assessments to accurately reflect the resident’s current status in the facility because inaccurate status could affect billing and census, and she acknowledged that the discharge MDS assessments for these two residents were inaccurate and should have indicated discharge–return not anticipated.
Improper Labeling, Dating, and Storage of Food and Beverages in Nutrition Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s food and nutrition services related to improper storage, labeling, and dating of food and beverages in the north and south nutrition room refrigerators. The facility’s written policy dated 05/01/23 required food and nutrition employees to prepare, label, and date evening snacks with a use-by date, affix labels including the resident’s name, current date, and use-by date, and ensure pantries were stocked with covered, labeled, and dated items. Despite this policy, observations on 03/09/26 in the south nutrition room revealed one pitcher of a pink-colored beverage and one pitcher of a purple-colored beverage stored in the refrigerator without labels or dates. Additionally, eight pre-packaged peanut butter and jelly sandwiches dated 02/07/26, four pre-packaged turkey sandwiches dated 02/08/26, three Vital Cuisine nutritional supplement shakes dated 03/03/26, and three small pre-packaged containers of strawberries dated 03/05/26 were stored in the refrigerator. Further observations on 03/09/26 in the north nutrition room showed six pre-packaged peanut butter and jelly sandwiches dated 02/07/26, two pre-packaged turkey sandwiches dated 02/08/26, and two Vital Cuisine nutritional supplement shakes dated 03/03/26 stored in the refrigerator, along with three 4-oz pre-packaged containers of chocolate pudding that were not labeled. During an interview on 03/10/26, the Dietary Manager stated that Dietary Aides were responsible for delivering and checking for expired resident snacks in both nutrition rooms three times daily, confirmed that expired food should be discarded, and that all food and beverage items should be labeled and dated. In a separate interview, the Administrator stated her expectation that residents do not receive or consume expired foods and acknowledged that residents could become ill if they consume expired foods.
Failure to Ensure Resident Call Lights Were Kept Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach for three residents. During an observation on 03/10/26 at 10:52 a.m., Resident #25 was seen sitting in bed, appearing uncomfortable and calling out for staff, while his call light was on the floor behind the bed and out of his reach; he confirmed he could not reach it. At 10:54 a.m. the same day, Resident #26 was observed sitting in bed watching television with the call light on the floor under the bed and not accessible. On 03/11/26 at 12:47 p.m., Resident #27 was observed lying in bed with the call light located under the bed and not within reach. Certified Nursing Assistant (CNA) #3 confirmed that call lights should always be within reach of residents and acknowledged that the call lights for Residents #25, #26, and #27 were not within reach as they should have been, further stating that if a call light was not in reach, it could cause a resident to fall. The Unit Manager (UM) #1 stated that staff are responsible for ensuring call lights are within residents’ reach and agreed that the call lights for these three residents were not within reach as required. These observations and staff interviews show that, at the times noted, the facility did not maintain accessible call lights for the three residents, despite staff acknowledging the expectation that call lights be kept within residents’ reach.
Unauthorized Use of Deceased Resident’s Debit Card by Facility Employee
Penalty
Summary
The facility failed to protect a resident’s personal funds from misappropriation when a facility employee used the resident’s debit card without authorization. The resident had been admitted with a diagnosis of failure to thrive and later died in the facility. After the resident’s death and discharge, bank records showed multiple processed transactions on the resident’s debit card, including charges at a restaurant, grocery store, drug store, coffee shop, donut shop, and dry cleaners. These transactions occurred on and after the date of the resident’s death. The resident’s daughter reported that she discovered the unauthorized charges after her mother died and confirmed with the bank that the charges began on the day of death. She filed a police report and stated that the facility was contacted and video footage confirmed a facility employee using the resident’s debit card. The Administrator confirmed that the family reported unauthorized use of the debit card, that an investigation was initiated with local law enforcement, and that police obtained video surveillance showing a facility employee using the resident’s debit card after the resident’s death. The Administrator acknowledged that a facility employee used the resident’s debit card and that this should not have occurred.
Oxygen Administered Without Physician Order
Penalty
Summary
Facility staff administered oxygen to a resident without a physician’s order, failing to ensure services met professional standards of quality. The resident was admitted with chronic systolic congestive heart failure and chronic obstructive pulmonary disease. Nursing progress notes documented that the resident was provided oxygen via nasal cannula on three separate dates (01/11/26, 02/20/26, and 02/23/26). However, review of the electronic health record on 03/09/26 showed there were no past or present physician orders for oxygen use for this resident. During observation of the resident’s room on 03/09/26, surveyors noted an oxygen concentrator with a nasal cannula attached and a portable oxygen tank available for use. In an interview, the resident stated he uses oxygen when he has difficulty breathing. The Unit Manager stated that all residents who need supplemental oxygen should have a physician’s order for PRN or continuous use and confirmed that this resident did not have such an order. The Administrator also stated her expectation that all residents requiring supplemental oxygen have a valid physician’s order and acknowledged that receiving oxygen without an order could result in the wrong treatment and pose a risk to resident safety and health.
Repeated Unavailability of Specialty Medication Leads to Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Eltrombopag Olamine 50 mg PO daily for chronic thrombocytopenia was not administered on multiple occasions due to the medication not being available in the facility. The resident, admitted with a femur fracture and diagnosed with low platelets, had physician orders specifying daily administration of Eltrombopag Olamine and instructions to reorder when only 10 tablets remained. Review of the MAR showed the medication was not administered on multiple date ranges, and nursing progress notes repeatedly documented that the medication was either not in stock, not available in the facility, or that staff were waiting on delivery from the pharmacy. During interviews, the resident reported not receiving the Eltrombopag Olamine for several days and stated this had happened multiple times before. The UM confirmed the resident had missed several doses because the medication had not yet arrived and acknowledged this was not the first time the medication was unavailable. The RN stated it was her expectation that all residents receive medications as ordered and noted that missing this medication could affect platelet function in the event of bleeding. The Medical Director reported being aware of issues with the resident not receiving the medication as ordered, explained that the drug was obtained through a specialty pharmacy with refill delays of a week or more, and attributed the problem to inconsistent ordering practices by different staff, with no single person consistently ensuring timely delivery. The facility’s own Medication Administration Policy required medications to be administered according to prescriber orders and appropriate interventions for medication errors, which did not occur in this case.
Failure to Use Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to utilize enhanced barrier precautions (EBP), specifically the use of gowns and gloves, during high-contact care activities for a resident with multiple open wounds. According to the facility's EBP policy, staff are required to use targeted personal protective equipment during activities such as dressing, bathing, hygiene, and transfers for residents at risk of multidrug-resistant organism (MDRO) transmission. Record review showed that the resident was dependent on staff for all activities of daily living, had multiple pressure ulcers, and required total assistance with hygiene and toileting. During an observed episode of incontinent care and repositioning, staff did not wear a gown and gloves as required by policy. Interviews with staff revealed inconsistent compliance with EBP. An LPN acknowledged that staff often only wore gloves, unless the wound was heavily draining, and did not always use gowns and gloves unless the resident was on isolation precautions. The Director of Nursing confirmed that staff were expected to follow the EBP policy but admitted that compliance was not always consistent, especially when residents became agitated or resisted care. The failure to follow EBP was directly observed and confirmed through staff interviews.
Failure to Develop and Implement Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a resident with complex medical needs and a high risk for falls. Upon admission, the resident had diagnoses including nontraumatic acute subdural hemorrhage, hemiplegia, generalized muscle weakness, and a history of transient ischemic attack. The resident's fall risk assessment indicated a high risk, with contributing factors such as incontinence, impaired gait and balance, recent hospitalization, and predisposing conditions like stroke and arthritis. Despite these findings, the baseline care plan created did not address essential areas such as initial goals based on admission orders, physician and dietary orders, therapy and social services, fall risk, fall prevention interventions, or assistance needs related to activities of daily living, bed mobility, or call light use. The care plan only included the resident's personal interests. Progress notes documented that the resident was lethargic and had ongoing concerns about bleeding risks and supervision needs, as expressed by her son. The resident experienced a non-witnessed fall and was transported to the emergency room, but there was no documentation that the baseline care plan was reviewed or revised following the incident. Further notes indicated the resident was unable to use the call light independently and required staff repositioning, yet these needs were not reflected in the care plan. Interviews with facility staff, including the Unit Manager, Administrator, and DON, confirmed that the expectation was for a complete baseline care plan to be in place within 48 hours, and that the resident's high fall risk should have been addressed in the care plan. However, staff were unaware that a complete plan had not been developed. The resident's son reported that he had communicated his concerns about his mother's fall risk, sedation, and inability to move independently to the nursing staff, and had requested bed rails. He was notified by the facility after his mother fell out of bed and was sent to the emergency room. The resident did not return to the facility after the hospital visit. Staff interviews further confirmed that the resident's high fall risk and need for frequent checks and repositioning were not adequately care planned, and that the required baseline care plan was not completed within the mandated timeframe.
Failure to Honor Resident Preferences in Bathing and Bed Positioning
Penalty
Summary
The facility failed to honor the personal preferences of four residents regarding their bathing routines and bed positioning. Resident #14 expressed a preference for showers over bed baths, yet records showed that he received only bed baths over a three-month period, despite the facility's schedule indicating he should have been offered showers twice a week. Similarly, Resident #59, who preferred more frequent bathing, received only four bed baths since her admission, contrary to the scheduled twice-weekly showers. The Director of Nursing confirmed these discrepancies, acknowledging that the residents' preferences were not being met. Resident #49, who has normal cognitive abilities and a preference for bed baths due to safety concerns with shower transfers, reported receiving only four bed baths over three months. Despite her clear communication of this preference to staff, the facility's records did not reflect additional bathing events. The Assistant Director of Nursing confirmed the limited documentation and acknowledged the resident's ability to express her needs and preferences. Resident #71 preferred to keep his bed in a high position when not in use to prevent other residents from accessing it. However, the facility implemented a practice of lowering beds to prevent falls, which was not documented in the facility's fall management protocol. This practice was applied to Resident #71 without his consent, causing him distress. The Administrator clarified that the intention was to apply this practice to vacant rooms, not occupied ones, and confirmed that the new process was not part of the current fall protocol.
Care Plan Deficiencies for Multiple Residents
Penalty
Summary
The facility failed to update and revise care plans for six residents, leading to deficiencies in their care. For one resident, the care plan did not include hospice care despite a physician's order for hospice services. Another resident did not have a quarterly care plan meeting for over a year, contrary to the requirement for such meetings to occur quarterly. Additionally, a resident receiving dialysis three times a week did not have this service included in their care plan. Further deficiencies were noted in the care plans of other residents. One resident's care plan did not reflect their current diet, as they were being served double portions without an order. Another resident's care plan lacked documentation for diabetic management, insulin use, pain management, and oxygen use, despite having physician orders for these treatments. Lastly, a resident's care plan did not include their oxygen use, which was ordered as needed. These omissions in care planning could result in staff being unaware of the residents' care needs and preferences.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for three out of five residents reviewed. This deficiency was identified through record reviews and interviews, revealing that pharmacist recommendations were not consistently reviewed or acknowledged by the providers. Specifically, the pharmacist's recommendations for medication modifications and considerations for gradual dose reductions (GDR) were not documented as reviewed or signed by the providers, indicating a lack of follow-through on critical medication management processes. For Resident #7, multiple pharmacist recommendations were made over several months, including suggestions for medication modifications and the need for blood sample orders to monitor diabetic therapy. However, there was no evidence that these recommendations were reviewed or acted upon by the provider, as the documents lacked signatures or confirmations of receipt. Similar issues were noted for Resident #27 and Resident #67, where recommendations for GDR and medication renewals were not documented as reviewed by the providers. The Director of Nursing confirmed during an interview that the expectation was for all pharmacist recommendations to be reviewed and signed by the provider, which was not the case for the cited recommendations. This oversight in the medication review process could lead to residents receiving unnecessary or ineffective medications, as the pharmacist's input was not being integrated into the residents' care plans.
Medication Administration Errors Due to Staffing Issues
Penalty
Summary
The facility failed to administer medications to two residents with an error rate less than 5%, resulting in a 45.45% error rate. For one resident, Methacarbamal, prescribed for muscle spasms, was administered at 8:34 am instead of the scheduled 7:00 am, as confirmed by the Certified Medication Aide (CMA) who acknowledged the medication was late. The Medication Administration Record (MAR) corroborated the scheduled time, and the CMA admitted the medication was administered more than one hour past the due time, which is considered late. For another resident, a total of 14 medications, including those for blood pressure, muscle spasms, eye conditions, allergies, urinary tract infection prevention, depression, enlarged prostate, nasal congestion, pain, seizure disorder, gastritis, and constipation, were all administered at 8:55 am instead of the scheduled 7:00 am. The CMA responsible for administering these medications confirmed they were late, stating that medications should be administered no later than one hour past the due time. The CMA also mentioned being the only nurse available to administer medications to her units, leading to frequent delays due to staffing issues.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year, as mandated. This deficiency was identified for three CNAs out of five randomly reviewed. Specifically, CNA #1, hired on June 6, 2022, did not complete the required 12 hours of in-service training for the period from June 6, 2023, through June 6, 2024, despite working sixteen shifts between January 25, 2025, and February 25, 2025. Similarly, CNA #3, hired on October 16, 2020, also failed to complete the required training hours for the period from October 16, 2023, through October 16, 2024, while working sixteen shifts in the same timeframe. CNA #4, hired on August 25, 2017, did not complete the required 12 hours of in-service training for the period from August 25, 2023, through August 25, 2024, and worked fifteen shifts between January 25, 2025, and February 25, 2025. The Nurse Educator confirmed during interviews that these CNAs did not complete the necessary training hours. The Director of Nursing also stated that all CNAs should have their 12 hours of in-service training completed if they are working on the floor with residents.
Breach of Resident PHI Due to Inadequate Safeguarding
Penalty
Summary
The facility failed to safeguard clinical record information, resulting in a breach of privacy for a resident. During an observation, a Certified Medication Aide (CMA) left a computer screen open and a narcotic book visible, exposing a resident's personal health information (PHI) to unauthorized individuals. Additionally, a narcotic record was left face up on the counter at the nurses' station. A Licensed Practical Nurse (LPN) confirmed these observations, acknowledging that the computer screen, narcotic book, and narcotic record should not have been left accessible to unauthorized residents, visitors, and staff.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as R #46, who reported that a night shift CNA was hateful towards him and instructed him not to use his call light for the rest of the night. This incident was initially reported by the resident to CNA #2 during a lunch observation, who then informed the Unit Manager (UM) #1. However, there was no documentation in the nursing progress notes regarding this allegation, and the UM was not made aware of the incident. Further interviews revealed that the Licensed Practical Nurse (LPN) #1, the Director of Nursing (DON), and the Administrator (ADM) were also unaware of the incident. The ADM, who is the abuse coordinator, confirmed that the allegation should have been reported immediately to initiate a thorough investigation. The failure to report and investigate the allegation of abuse indicates a breakdown in the facility's protocol for handling such incidents, potentially putting residents at risk of adverse outcomes.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge planning for two residents, leading to significant deficiencies in their care. Resident #104 was discharged without the necessary home health services in place, despite physician orders and care plan notes indicating the need for such services. The facility's Social Services Director (SSD) and Social Services Assistant (SSA) were responsible for coordinating these services through a third-party company. However, due to a lack of communication and follow-up, the home health agency did not accept the resident's insurance, resulting in the resident being discharged without the required care. Interviews with the resident, her son, and facility staff confirmed that the necessary services were not established prior to discharge. Resident #122 was discharged from the facility without proper notice or intervention for her behaviors. She had called 911 due to not feeling well and was transported to the hospital. The facility decided not to allow her back due to her physical aggression towards staff, and she was given an immediate discharge notice at the hospital. Interviews with the Director of Nursing (DON), the resident's son, and the Administrator confirmed that the resident was not allowed to return to the facility due to safety concerns related to her behavior. These deficiencies highlight the facility's failure to ensure that residents are adequately prepared for discharge, either by securing necessary home health services or by providing appropriate notice and intervention for behavioral issues. The lack of communication and follow-up in both cases resulted in residents being discharged without the support and care they required, potentially leaving them vulnerable and without necessary assistance.
Hospice Services Provided Without Physician Orders
Penalty
Summary
The facility failed to meet professional standards of quality by providing hospice services to a resident without obtaining the necessary physician orders. The resident was admitted to the facility and began receiving hospice care services as indicated in their care plan. However, a review of the resident's physician orders revealed that there were no orders present for the hospice care services. During an interview, the Director of Nursing confirmed that the resident started hospice services on February 1st and acknowledged that physician orders should have been obtained prior to the initiation of hospice care, but they were not.
Inadequate Care Leads to Resident's Wound Development
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident, identified as R #114, to maintain her overall well-being. Observations and interviews revealed that the resident, who was non-responsive and slumped in her wheelchair, was not repositioned or had her brief changed frequently enough to prevent the development of a wound. The resident's son and daughter reported finding her in a wet or soiled brief during their visits, indicating a lack of timely care by the staff. The resident's care plans highlighted her risk for skin breakdown due to limited mobility and incontinence, necessitating regular repositioning and brief changes. The Wound Care Nurse confirmed that the resident developed a wound on her buttock area due to moisture accumulation in her brief, which was not changed as frequently as needed. The wound was first identified on 02/12/25 and was attributed to the resident not being assisted with changing positions and inadequate brief checks. The resident's medical history included significant impairments following a stroke, making her dependent on staff for all activities of daily living, including toileting and mobility, which were not adequately addressed by the facility.
Failure to Provide Fall Mat for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as R #58, was provided with a fall mat to reduce injury from falling, as outlined in the resident's care plan. R #58 was admitted with diagnoses including diabetes mellitus, repeated falls, and an acquired absence of the left leg above the knee. The resident's care plan, dated 12/12/24, specifically included the use of a fall mat to prevent falls. However, observations on 02/18/25 and 02/20/25 revealed that no fall mat was present beside the resident's bed, despite the resident having a history of falls from the bed to the floor, as documented in daily care notes on multiple occasions. The Director of Nursing confirmed the absence of the fall mat during an interview on 02/20/25.
Failure to Maintain Filled Portable Oxygen Tank
Penalty
Summary
The facility failed to ensure a portable oxygen tank was filled with oxygen for a resident who required respiratory care. The resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), reported that the portable oxygen tank leaked and did not hold oxygen, rendering it unusable. Despite informing several staff members about the issue, no action was taken to address the problem. A physician's order indicated the resident required 2 liters of oxygen via nasal cannula to maintain oxygen saturation levels above 92% as needed. During interviews, a Certified Medication Aide and a Registered Nurse confirmed that the portable oxygen tank was empty, acknowledging that it should always be full and ready for use.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure proper storage and administration of medications, as observed during a survey. On February 24, 2025, an inspection of the south side medication cart revealed five unidentified loose pills in the second drawer, indicating improper storage. Additionally, a narcotic medication, Pregabalin, was signed out as administered to a resident but was still present in the medication card, suggesting it was not given as recorded. During an interview, a Certified Medication Aide (CMA) confirmed the presence of the loose pills and admitted to signing out the Pregabalin without administering it, contrary to the Medication Administration Record (MAR). The Director of Nursing (DON) acknowledged that medication carts should be checked daily, loose medications discarded, and any unadministered medications reported and documented, as failing to do so constitutes a medication error.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature for a resident reviewed for meal quality. During an interview, the resident reported that the food was often cold when delivered to his room for lunch. An observation of the lunch meal revealed that the temperatures of the tamale, black beans, and coleslaw were 117, 110, and 112 degrees Fahrenheit, respectively. These temperatures were confirmed by the Dietary Manager and the DC to be below the appropriate serving temperature of 135 degrees Fahrenheit or higher.
Failure to Follow Resident's Food Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, specifically regarding their dislike for eggs. During an interview, the resident expressed dissatisfaction with being served cold eggs for breakfast, which they did not like. An observation confirmed that the resident was served eggs, which they left uneaten. A review of the resident's meal ticket showed no indication of their dislike for eggs. The Dietary Manager, responsible for interviewing residents about their food preferences upon admission and reviewing them quarterly or as needed, was unaware of the resident's aversion to eggs.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to ensure the completeness of medical records for a resident, identified as R #89. Upon review, it was found that R #89's Electronic Medical Record (EMR) did not contain a Pre-Admission Screening and Resident Review (PASRR), which is a federally required document for individuals admitted to Medicaid-certified nursing facilities. The absence of this document was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the PASRR should have been included in the resident's admission records. This oversight in maintaining complete medical records could impede the staff's ability to provide competent and comprehensive care to the resident.
Lack of Coordinated Hospice Care Plan
Penalty
Summary
The facility failed to ensure collaboration between the facility and hospice services for a resident receiving hospice care. The deficiency was identified through a record review and interviews, revealing that a coordinated plan of care was not developed for the resident. The resident's admission Minimum Data Set (MDS) indicated they were on hospice care, but there was no hospice communication documentation in the medical record. The Director of Nursing in Training (DON-IT) mentioned that a hospice binder, which should contain written communication and the coordinated plan of care, was not available at the nurse's station or in medical records. The Director of Nursing (DON) confirmed the absence of hospice communication documentation, which should have been present.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance with bathing and showering, which is a critical aspect of maintaining personal hygiene and performing activities of daily living (ADLs). The resident, who was admitted with diagnoses including unspecified dementia, urinary incontinence, chronic respiratory failure with hypoxia, and nonrheumatic aortic stenosis, was scheduled to receive showers on Mondays and Thursdays. However, records indicate that the resident did not receive a shower from July 11, 2024, through August 11, 2024, with only one documented refusal on July 18, 2024. On several other dates, staff either marked the shower as 'not applicable' or failed to document whether the shower was completed. The lack of documentation and failure to provide scheduled showers suggest a breakdown in the facility's processes for ensuring residents receive necessary care. The Director of Nursing (DON) acknowledged the issue and noted that a new system had been implemented to ensure compliance with shower schedules. However, the deficiency occurred before this system was put in place, indicating that the previous system was inadequate in ensuring that residents received the care they needed. The failure to provide scheduled showers could lead to a decline in the resident's ability to maintain personal hygiene, which is essential for their overall health and well-being.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is crucial for assessing health status in nursing home residents. The resident was admitted with a history of sepsis, urinary tract infection, benign prostatic hyperplasia, and obstruction and reflux uropathy. However, discrepancies were found in the documentation regarding the presence of an indwelling catheter. The resident's face sheet and nursing admission assessment indicated that the resident was not admitted with a catheter and was continent of bladder, while the MDS assessment inaccurately recorded the presence of an indwelling catheter. Further review of nursing progress notes revealed that the resident requested the re-insertion of a Foley catheter, which he had used for over a year, but was not retaining urine as per bladder scans. The resident eventually left the facility against medical advice, insisting on having the catheter reinserted. Interviews with the Director of Nursing confirmed that the MDS assessments were incorrect, as the resident did not have a catheter upon admission. This inconsistency between the MDS, nursing admission assessment, and hospital discharge documentation led to the deficiency.
Delayed Meal Service and Inconsistent Delivery in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received their meals in accordance with the scheduled meal times, as observed during a survey. The meal schedule indicated that breakfast should be served at 7:15 am, lunch at 12:00 pm, and dinner at 5:15 pm. However, on the day of observation, lunch meal carts were delivered significantly late to two different halls, with one cart arriving at 1:12 pm and the other at 1:27 pm. This delay resulted in one resident receiving their lunch at 1:28 pm, while their roommate did not receive a meal until 1:43 pm. Interviews with the Director of Nursing and dietary staff revealed that such delays were common, with the kitchen often forgetting to send trays or being backed up, leading to inconsistent meal delivery times. Additionally, another resident reported that their meals were consistently delivered late, and there were instances where staff forgot to send meals, resulting in the delivery of an empty plate. This resident could not recall the exact number of times or the last occurrence of receiving an empty plate. These observations and interviews highlight a pattern of meal delivery issues within the facility, potentially impacting residents' nutritional intake and satisfaction with their care.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for at least 8 hours during each 24-hour period, as required. This deficiency was identified through a review of the facility's staffing schedule for the months of April, May, June, and July 2024, which revealed multiple days where no RN was scheduled to provide direct patient care. Specifically, the absence of an RN was noted on several days across these months. During an interview on August 15, 2024, the Scheduling Manager and the Administrator acknowledged the issue, citing a shortage of nurses as the reason for the lapses in RN coverage. This deficiency potentially affects all 114 residents in the facility, as it may result in them not receiving the necessary services. The report does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Failure to Maintain Accurate Resident Weights
Penalty
Summary
The facility failed to maintain accurate weights for a resident, which is a deficiency in meeting professional standards of quality. The resident in question was admitted with several diagnoses, including altered mental status, Parkinson's disease, ulcerative chronic proctitis, vascular dementia, and severe protein-calorie malnutrition. According to the physician's orders, the resident was supposed to be weighed weekly for four weeks and then monthly. However, the medical record only contained one weight entry, indicating a failure to follow the prescribed weight monitoring schedule. Interviews with the Director of Nursing (DON) and the Restorative Aide (RA) revealed a lack of clarity and communication regarding the responsibility for weighing residents. The DON stated that residents should be weighed weekly upon admission, but this was not done. The RA mentioned that the restorative program, which began in March, was responsible for weighing residents, but she was unaware if weights were being recorded before the program started. This lack of adherence to the weight monitoring protocol could lead to inadequate assessment of the resident's nutritional status.
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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