Spanish Trails Rehabilitation Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 1610 N Renaissance Blvd Ne, Albuquerque, New Mexico 87107
- CMS Provider Number
- 325131
- Inspections on file
- 41
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Spanish Trails Rehabilitation Suites during CMS and state inspections, most recent first.
Two residents experienced medication-related deficiencies when staff failed to follow professional standards for medication availability, administration, and monitoring. One resident with an order for Jardiance to control blood sugar had the drug marked as given on the MAR on several days even though it was not available and not administered, while an LPN checked the resident’s blood sugars without a physician’s order and did not document the results. Another resident with a history of cerebral infarction and hemiplegia had multiple ordered warfarin doses missed, and the DON later confirmed the missed doses and stated she had not been informed that the high-risk medication had not been given as ordered.
A resident with multiple medical conditions, including osteoporosis, epileptic spasms, GERD, post-stroke hemiplegia/hemiparesis, insomnia, and recurrent major depressive disorder, did not receive an accurate MDS assessment when the BIMS cognitive interview was omitted on a scheduled assessment. A prior MDS had documented a BIMS score of 15, but the later assessment lacked any BIMS evaluation. The MDS coordinator confirmed that this assessment was completed remotely rather than in person and acknowledged that the absence of the BIMS made the MDS inaccurate.
A resident admitted with hemiplegia following a cerebral infarction, generalized muscle weakness, need for assistance with personal care, and chronic migraine had physician orders for low-dose aspirin for clot prevention and warfarin for cerebral infarction. The baseline care plan, completed after admission, noted full code status, fall risk related to psychotropic use, poor balance and weakness, and potential for pain, but did not address the resident’s anticoagulant therapy. In an interview, the DON confirmed that the baseline care plan omitted anticoagulant use and was not completed within the required 48-hour timeframe.
A resident was admitted with multiple diagnoses, including osteoporosis, epileptic spasms, GERD, hemiplegia/hemiparesis after cerebral infarction, insomnia, recurrent major depressive disorder, dementia, and a need for ADL assistance. Review of the care plan showed it only addressed elopement risk, dementia-related nutritional risk, and behavior changes after stroke, while omitting other significant conditions such as epileptic spasms, GERD, insomnia, depression, and ADL needs. During interview, the DON confirmed these omissions and acknowledged that the care plan was not person-centered and did not reflect the resident’s overall condition.
A resident with a history of CVA, falls, poor safety awareness, and cognitive impairment, whose care plan called for frequent observation and supervised placement when out of bed, was transported alone to a follow-up medical appointment and left unattended. Family members reported that the physician’s office called them expressing concern about the resident’s safety and that the resident was found sitting in a wheelchair without having been seen by the doctor. Transport staff stated they were trained that drivers only provide transportation and no patient care, and that they rely on the DON’s notation on the appointment sheet to know if an escort is needed. An LPN reported that not all residents go to appointments with escorts and that the scheduler would know if an escort was required, and she was unaware that this resident had been left alone.
A resident with hemiplegia and hemiparesis following a cerebral infarction, along with other conditions including generalized muscle weakness and chronic migraine, had multiple changing physician orders for warfarin to treat cerebral infarction affecting the left dominant side. Review of the MAR showed that three ordered doses of warfarin were not administered, and in an interview the DON confirmed the missed doses, acknowledged that warfarin is a high-risk medication that must be given as ordered, and stated she had not been informed of the missed doses or any medication unavailability.
A resident with a history of aggression and multiple behavioral health diagnoses was involved in a physical altercation with a CNA after staff failed to follow the resident's request and lacked appropriate de-escalation training. The incident resulted in the resident falling and sustaining an injury, highlighting the facility's failure to provide necessary behavioral health care and adequate staff training to manage aggressive behaviors.
A resident with complex medical needs did not receive weekly skin assessments as ordered, resulting in missed documentation and the development of a stage 2 pressure ulcer. Additionally, there was a significant delay in obtaining a physician's order and completing a swallow study after repeated recommendations by the SLP, due to poor communication between nursing and therapy staff.
Two residents who were dependent on staff for toileting and incontinent care did not receive timely brief changes, with documentation and staff interviews confirming that one resident went an entire shift without assistance and another was changed only one or two times per day despite frequent incontinence and skin breakdown.
A resident with significant care needs, including incontinence and dependence on staff for toileting, was left without assistance throughout an overnight shift. Documentation and investigation confirmed that the resident was not provided care, was left in a soiled brief, and call light requests were ignored by a CNA, resulting in substantiated neglect.
A resident with multiple chronic conditions was left without care by a CNA for most of a 12-hour shift. Although the administrator initiated an investigation by phone, there was no written documentation of interviews or follow-up actions, resulting in a deficiency for failure to document the investigation.
A resident admitted with heart failure, Parkinson's disease, and respiratory failure did not have a comprehensive care plan developed during their stay. Although an initial care plan and some updates were present, a full comprehensive care plan was not completed, as confirmed by the interim DON after reviewing the medical record.
A resident with GERD, diabetes, and other conditions did not receive medications with meals as ordered by a physician. The resident reported a preference for taking medications with food to reduce stomach irritation, but an LPN considered the order outdated and did not follow it after the resident's hospital stay, resulting in the resident not receiving medications as ordered.
The facility did not consistently protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
Two residents experienced significant financial losses due to unauthorized use of their debit cards, with one losing $1,300 after hospitalization and another discovering $23,000 missing from his account. Facility staff failed to promptly report or investigate the incidents, and did not assist in obtaining necessary documentation, allowing the misappropriation to go undetected.
A resident with multiple serious health conditions was transferred to the hospital several times due to changes in condition, but the provider and emergency contact were not notified as required. Documentation and staff interview confirmed the lack of communication regarding these hospital transfers.
Staff did not conduct required quarterly care plan meetings for several residents, resulting in overdue reviews and updates of care plans. Additionally, a resident's care plan was not updated to reflect that the resident and family were providing colostomy care, despite staff and family confirming this arrangement.
Staff did not ensure proper labeling, dating, and storage of food items, with several foods found unlabeled, undated, left open to air, or stored past expiration in the kitchen and dry storage. The Dietary Manager confirmed these lapses, which affected all residents in the facility.
A resident developed a sore and redness near the right eye, reported pain, and stated that nursing staff had not examined the area. The DON was unaware of the issue, and review of shower sheets showed no documentation or assessment of the skin condition, despite facility protocols requiring such actions.
A nurse entered a bathroom without announcing herself while a resident was being assisted with a shower by a CNA, resulting in the resident feeling that her privacy and dignity were not respected. The resident, who is cognitively intact and requires significant assistance with bathing, expressed that the unannounced entry made her uncomfortable, and this was confirmed by her roommate. Facility staff acknowledged that the expected protocol is to knock and announce before entering during personal care, but this was not followed in this instance.
A resident with multiple complex diagnoses was transferred to the hospital after exhibiting significant changes in condition, including reduced strength and slurred speech. The facility completed required MDS discharge and entry assessments but did not complete a significant change in status assessment within the required timeframe. The DON and MDS coordinator were unsure if this assessment was needed.
A resident on Warfarin experienced an unwitnessed fall, but facility staff did not immediately notify the provider or the resident's emergency contact. The incident was only documented later, and the family learned of the fall after visiting. The resident, with a history of fractures, developed new symptoms and was later found to have rib fractures after being sent to the hospital by family. Staff interviews confirmed that required notifications were not made.
A resident was repeatedly administered oxygen therapy without a physician's order, as confirmed by documentation in the EHR and interviews with staff and the emergency contact. The DON verified that no order was present despite frequent oxygen use.
A resident with specific dietary restrictions and preferences was repeatedly served foods she could not eat, such as vegetables and mashed potatoes, despite clear instructions on her meal ticket. Staff interviews and meal observations confirmed that her dietary needs were not being followed.
A resident's grievance regarding cold meals, hair in food, and delayed CNA assistance was inadequately investigated by the facility. The Social Services Director only addressed the food temperature issue without taking actual measurements and ignored other concerns. The resident remained dissatisfied, and the Administrator admitted the grievance was not properly resolved.
The facility failed to conduct timely care plan meetings for two residents, resulting in outdated care plans. One resident had their last meeting in July and could not recall a recent meeting, while another expressed a desire for a meeting. The Social Services Director confirmed that both residents were overdue for quarterly care plan meetings, indicating a failure to update and address their care needs.
The facility failed to communicate critical lab results timely and ensure medication availability for two residents. One resident's critical lab results were not conveyed to the provider promptly, delaying medical intervention. Another resident did not receive their prescribed Eliquis due to unavailability, and the nurse did not check the Pyxis or notify the provider.
A facility experienced a medication error rate of 23.08% due to the unavailability of Eliquis for a resident, despite it being prescribed for daily administration. RN #2 administered other medications as ordered, but the failure to provide Eliquis contributed to the high error rate. The ADON confirmed that medications should be administered within a specific timeframe, and deviations are considered late.
The facility failed to serve meals at safe temperatures, affecting four residents who reported receiving cold food despite complaints. Observations showed food on the steam table was below safe temperatures due to a malfunctioning steam table. Staff interviews confirmed the issue, and a resident had filed a grievance about the cold meals.
A facility failed to ensure proper infection control practices during medication administration when an RN did not wash his hands before, during, or after administering medications to two residents. The RN admitted to not using the hand wash stations available in the resident rooms, and the DON confirmed that staff should wash hands before and after medication administration.
A resident was not assisted with purchasing painting materials and winter clothes after the departure of the previous SSD who used to help with these purchases. The resident, who enjoys activities like painting and reading, repeatedly asked facility staff for assistance but did not receive help. The facility administrator confirmed the oversight.
A resident who followed a vegan diet was admitted to the facility with a regular diet order. Despite informing staff of her vegan preference, she continued to receive non-vegan meals. The absence of the Kitchen Manager, who typically conducted dietary preference interviews, led to a lack of communication and follow-up, resulting in the resident not receiving appropriate meals.
A resident was not provided with the prescribed therapeutic diet, receiving mechanical soft meatloaf instead of the ordered pureed diet. This discrepancy was confirmed by dietary staff, highlighting a failure to adhere to the physician's dietary orders.
A resident did not receive necessary assistance with toileting and brief changes, as staff failed to enter the room throughout the day. The resident's daughter discovered this through an in-room camera. The CNA responsible admitted to not checking on the resident during her shift, leading to the CNA's dismissal.
A resident in an LTC facility experienced worsening pressure ulcers due to inadequate monitoring and communication. Staff failed to identify and document the resident's pressure ulcers upon admission and did not update treatment orders or notify the physician of the worsening condition. The resident's ulcers progressed to stage 4, leading to hospitalization and hospice care. Interviews revealed a lack of communication and documentation among staff regarding the resident's deteriorating condition.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including improper maintenance of ice machines, inadequate hand hygiene and glove use by staff, and failure to protect clean dishes from contamination. Additionally, pureed food was not served at appropriate temperatures, and there were issues with labeling and storing food items. The kitchen environment was not maintained in a clean manner, posing potential risks to residents.
The facility failed to update care plans for two residents regarding ADL needs and activity preferences, and did not inform a resident's POA about changes in behavioral symptoms. The DON and Activities Director confirmed these omissions, which could lead to unmet care needs.
Two residents in an LTC facility did not receive the scheduled number of baths or showers due to staff shortages. One resident, requiring partial assistance, often received only one shower a week, while another, needing maximal assistance, also missed scheduled bathing. Staff confirmed the deficiency, and the DON acknowledged the failure to meet care plans.
A facility failed to ensure medications were not left unattended on a resident's bedside table, posing a risk to residents on the 400 hall. During an observation, 12 pills were found on a bedside table, including Ranolazine, Mucus Relief DM, and Pantoprazole Sodium. Interviews with staff revealed that a CMA left the medications there, contrary to protocol requiring staff to observe residents taking their medications.
The facility failed to ensure staff followed nutritionally calculated recipes for pureed diets, affecting six residents. Staff did not measure ingredients accurately or follow recipes, as observed during meal preparation. The Dietary Manager admitted to not following a recipe due to time constraints and lack of awareness. The Registered Dietician confirmed that recipes are reviewed every six months and expected staff adherence.
The facility failed to follow infection control practices for four residents. Nasal cannulas were not labeled with change dates, and CPAP equipment and nebulizers were improperly stored. Staff interviews confirmed these lapses, which could lead to infection spread.
A resident who required a sippy cup for meals did not receive one, despite recommendations and physician orders. During a meal observation, the resident was served without the necessary device, and an LPN confirmed its absence.
The facility failed to honor a resident's rights by administering medication to reduce sexual desires without proper consent. Despite a psychologist's assessment that the resident could consent to sexual activity, the NP and Medical Director increased the resident's escitalopram dosage to dampen libido, citing concerns about decisional capacity.
A resident with multiple diagnoses, including vascular dementia and mood disturbance, was administered an increased dose of escitalopram without adequate indications. The increase was recommended to dampen the resident's libido following a sexual incident, despite no documented increase in depression. The Medical Director and Nurse Practitioner acknowledged the resident's inability to make informed decisions, yet the resident was his own decision maker.
Failure to Follow Professional Standards in Medication Availability, Administration, and Monitoring
Penalty
Summary
The deficiency involves failures to meet professional standards of quality in medication management and monitoring for two residents. For one resident with an order dated 12/16/25 for Jardiance 10 mg orally once daily to control blood sugar levels, the MAR from 01/29/26 through 02/06/26 showed the medication as administered on multiple dates (01/30/26, 01/31/26, and 02/04/26 through 02/06/26) despite the medication not being available. A CMA stated that the last actual dose was given on 01/28/26 and confirmed that she documented the medication as given on 01/30/26, 01/31/26, and 02/06/26 even though it was not available and not administered. An RN and an LPN both confirmed that the Jardiance had not been available since late January and that the resident had not been receiving it since that time. The LPN further reported that she had been checking the resident’s blood sugars without a physician’s order, was not documenting those blood sugar results in the chart, and was using the information only for her own reference. For another resident admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura, multiple warfarin dose changes were ordered over January 2026 for treatment of cerebral infarction affecting the left dominant side. Review of the January MAR showed that this resident missed warfarin doses on 01/18/26, 01/19/26, and 01/21/26. The DON confirmed that these warfarin doses were missed, acknowledged that warfarin is a high-risk medication that should be given as ordered, and stated she had not been aware that any doses were missed. The DON also stated she expects nurses to notify her and the pharmacy when medications are not available.
Inaccurate MDS Assessment Due to Omitted BIMS Evaluation
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident when the Brief Interview for Mental Status (BIMS) was not conducted as required. The resident had been admitted with multiple diagnoses, including age-related osteoporosis without current pathological fracture, epileptic spasms without status epilepticus, GERD without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified insomnia, recurrent moderate major depressive disorder, and a need for assistance with personal care. Record review showed that on a prior MDS dated 09/16/25, the resident’s BIMS score was documented as 15, indicating that a cognitive assessment had been completed at that time. However, review of the subsequent MDS dated 12/17/25 revealed that the resident was not assessed for BIMS at all. During an interview, the MDS coordinator confirmed that this assessment did not include an in-person evaluation and acknowledged that the MDS was completed remotely for this particular assessment. She further confirmed that the omission of the BIMS assessment made the MDS inaccurate, as the resident should have been assessed in person and the BIMS completed as part of the federally mandated assessment process.
Failure to Include Anticoagulant Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura. Physician orders for this resident included low-dose aspirin for clot prevention and warfarin sodium for cerebral infarction. The baseline care plan, dated several days after admission, documented that the resident had an advance directive of full code, was at risk for falls related to psychotropic medication use, poor balance, and weakness, and had potential for pain. However, the baseline care plan did not address the resident’s use of anticoagulant medication, despite active orders for aspirin and warfarin. During an interview, the DON confirmed that the baseline care plan did not include the use of anticoagulants and acknowledged that the baseline care plan should have been completed within 48 hours of admission, which did not occur.
Failure to Develop Comprehensive, Person-Centered Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan for one resident. Record review showed the resident was admitted with multiple diagnoses, including age-related osteoporosis without current pathological fracture, epileptic spasms not intractable and without status epilepticus, GERD without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified insomnia, recurrent moderate major depressive disorder, and a need for assistance with personal care. These conditions were pertinent to the resident’s care needs. Review of the resident’s care plan dated 01/21/26 revealed it addressed only certain issues: risk for elopement related to an elopement evaluation risk score, dementia placing the resident at risk for altered nutritional status, and a history of stroke affecting behavior with a tendency to make demands and inappropriate comments to staff. The care plan did not address other documented conditions such as epileptic spasms, GERD, cerebral infarction-related deficits, insomnia, major depression, and ADL needs. In an interview, the DON confirmed that these conditions were not included in the care plan and acknowledged that the plan was not person-centered and did not reflect the resident as a whole.
Failure to Provide Escort and Supervision for High-Risk Resident at Medical Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents when a resident with a history of falls and cognitive impairment was sent alone to a follow-up medical appointment. The resident had a history of cerebrovascular accident (CVA), poor safety awareness, and a tendency to move independently without using the call light or setting wheelchair brakes. The resident’s care plan, dated 09/27/25, included interventions such as more frequent visual rounding, offering frequent help as needed, and placing the resident in supervised areas when out of bed. Despite this, the resident was transported to a doctor’s appointment without an escort and was left unattended for an extended period. The resident’s brother reported receiving a call from the doctor’s office asking who was supposed to pick the resident up and expressing concern for his safety, and he stated that the facility did not respond when he called to ask why the resident was left alone. The resident’s sister stated that due to his cognitive ability he could not be left alone, that the facility had assured her he would not be left alone, and that he was found sitting in a wheelchair with a paper and likely was not seen by the doctor because he was alone and unable to care for himself cognitively. The central supply/transport driver stated she was not aware the resident needed someone to go with him and explained that the process relied on the DON marking the appointment sheet if an escort was required; she also stated they had been trained that drivers do not stay at appointments and provide no patient care. An LPN stated that not every person going to an appointment has an escort and that the person scheduling appointments would know if an escort was needed, and she was not aware of this resident being left alone at his appointment.
Missed High-Risk Warfarin Doses for Anticoagulation Therapy
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors involving the anticoagulant warfarin. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura. Physician orders showed multiple adjustments to the resident’s warfarin regimen over time, including varying dosages and schedules (daily dosing, then specific days of the week, and later a fixed daily dose) for treatment of cerebral infarction affecting the left dominant side. Record review of the January 2026 MAR revealed that three ordered doses of warfarin were not administered on 01/18/26, 01/19/26, and 01/21/26. During an interview, the DON confirmed that these warfarin doses were missed and acknowledged that warfarin is a high-risk medication that should be administered as ordered. The DON also stated she had not been aware that the resident had missed any warfarin doses and reported that her expectation is that nurses notify her and the pharmacy if a medication is not available.
Failure to Provide Necessary Behavioral Health Services and Staff Training
Penalty
Summary
The facility failed to ensure that a resident with a history of aggressive behaviors received the necessary behavioral health care and services to maintain their highest practicable well-being. The resident, who had diagnoses including cognitive communication deficit, depression, and a history of physically abusive behavior, was involved in an incident where he attacked a CNA, resulting in a fall and injury. The care plan for the resident identified aggressive and abusive behaviors, but interventions were limited to psychosocial therapy, 1:1 oversight as needed, and general support for anxiety and depression, without specific strategies for staff to manage or de-escalate aggressive incidents. On the night of the incident, the resident became upset after a wound dressing was changed and additional staff entered his room, which he perceived as threatening. Despite the resident's request for a particular CNA to leave, the CNA remained and attempted to provide care, leading to a physical altercation. The resident reported feeling provoked and acted in self-defense, resulting in a struggle and subsequent fall. Staff interviews confirmed that the resident was known for aggressive behavior and had a prior negative interaction with the CNA involved in the incident. The facility did not provide staff with de-escalation or specialized training for managing aggressive behaviors prior to the incident. Staff received only general abuse and neglect training upon hire, and there were no documented interventions or training in place to address the specific behavioral health needs of residents exhibiting aggression. This lack of appropriate staff training and tailored interventions contributed to the escalation of the situation and the resulting injury.
Failure to Follow Physician Orders for Skin Assessments and Timely Swallow Study
Penalty
Summary
The facility failed to provide quality care that meets professional standards for a resident with multiple diagnoses, including metabolic encephalopathy, dysphagia, moderate malnutrition, weakness, and dementia. Staff did not follow physician orders for weekly skin assessments, as evidenced by gaps in documentation and missed assessments over several weeks. The resident developed a stage 2 pressure ulcer and had ongoing skin issues, but weekly assessments were not consistently completed as ordered. Both a registered nurse and the interim director of nursing confirmed that the weekly skin assessments were not performed as required by the physician's orders. Additionally, the facility did not obtain a physician's order and complete a swallow study in a timely manner after it was recommended by the speech language pathologist (SLP). The SLP documented several recommendations for a swallow study over multiple weeks before an order was finally placed and the study was completed. Interviews with the SLP and the interim director of nursing confirmed that the delay was due to a lack of timely communication and follow-through between nursing staff and therapy, resulting in a significant delay in addressing the resident's swallowing difficulties.
Failure to Provide Timely Brief Changes and Daily Care
Penalty
Summary
The facility failed to provide adequate daily care, specifically timely brief changes, for two of three residents reviewed for care needs. One resident, who was dependent on staff for toileting and dressing due to conditions such as Parkinsonism and acute respiratory failure, had no documentation of assistance with toileting or brief changes during an entire evening shift. The Interim Director of Nursing confirmed that the resident's brief should have been changed during that time. Another resident, who had moisture-associated skin damage and was care planned for frequent brief checks and changes every two hours, was documented as having her brief changed only one or two times per 24 hours over multiple days. Skin assessments revealed the development of a stage 2 pressure ulcer and ongoing redness in the groin area. Interviews with the resident's son, CNAs, and RNs confirmed that the resident was not changed as frequently as required, and that this lack of care contributed to skin breakdown.
Failure to Provide Nighttime Care and Assistance
Penalty
Summary
A resident with multiple diagnoses, including Parkinsonism and acute respiratory failure with hypoxia, was admitted to the facility and required assistance with self-care, mobility, and was dependent on staff for toileting and dressing due to incontinence. The resident's care plan included encouragement to use the call light, monitoring for pain, and provision of medication as needed. On the night in question, there was no documentation of care provided by any CNA from the evening through the following morning, indicating that the resident did not receive assistance with toileting or brief changes during the entire shift. An incident report and subsequent investigation confirmed that a CNA failed to provide care to the resident throughout the night, leaving the resident in a urine-soaked brief and not responding to the call light. The neglect was substantiated by the facility's investigation, and the administrator confirmed being notified of the incident and verified the neglect occurred during the specified shift.
Failure to Document Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly document the investigation of an alleged neglect incident involving a resident with diagnoses including heart failure, Parkinson's disease, and respiratory failure. The incident involved a Certified Nurse's Aide (CNA) who was reported to have provided no care to the resident during a 12-hour overnight shift, leaving the resident in her room for most of that period. The administrator was notified of the incident and began an immediate investigation by contacting staff by phone. Despite initiating an investigation, the administrator did not provide any written documentation of the interviews conducted, the investigation process, or any follow-up training related to the incident. The only documentation available was a follow-up report summarizing the incident, with no supporting evidence or records of staff interviews or retraining. This lack of thorough documentation led to the deficiency cited in the report.
Failure to Develop Comprehensive Care Plan After Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident following their admission. Record review showed that the resident was admitted with diagnoses including heart failure, Parkinson's disease, and respiratory failure. The Minimum Data Set (MDS) 5-day admission assessment was completed and signed by the MDS RN, but a review of the electronic medical record for the resident's stay did not reveal a comprehensive care plan. Only an initial care plan and some additions were found, but no complete comprehensive care plan was documented. The interim Director of Nursing confirmed that, despite reviewing the care plan and electronic medical record, a comprehensive care plan had not been completed for the resident.
Failure to Follow Physician Order for Medication Administration with Meals
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for a resident with multiple diagnoses, including GERD, cognitive communication deficit, type 2 diabetes mellitus, and generalized anxiety disorder. The physician's order, dated 01/29/25, specified that all appropriate medications should be administered with food or a snack. On the day of observation, the resident reported having already eaten his meal but had not yet received his morning medications, expressing a preference to receive them with his meal to avoid stomach irritation. During interviews, an LPN stated that she considered the order to be a nursing order rather than a physician's order and believed it should have been discontinued after the resident's recent hospital stay. The LPN acknowledged discussing medication administration with the resident upon his return from the hospital and indicated she should have discontinued the order, as she believed it was no longer necessary. However, the resident continued to express a preference for receiving medications with meals, particularly in the morning, which was not being honored at the time of the survey.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review, indicating that the required protocols for protecting confidential resident information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the condition at the time of the deficiency are provided in the report.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of resident funds, resulting in unauthorized use of debit cards and significant financial losses for two residents. In one case, a resident was admitted to the hospital and subsequently passed away, after which $1,300 was withdrawn from her account. The facility was unable to determine who made the withdrawals or purchases, and all relevant information was turned over to law enforcement. The investigation could not substantiate abuse, neglect, or misappropriation, but the loss of funds remained unresolved. In another instance, a resident reported that his debit card had been stolen by a former CNA, who was related to a current staff member. The resident discovered the theft after being denied assistance due to the existence of a bank account with missing funds. Upon investigation, it was found that approximately $23,000 was missing from his account. The resident stated that he had given his food card and PIN to staff to purchase groceries, but did not recall giving his debit card, which was later found to be missing. The resident expressed feelings of betrayal and loss of trust as a result of the incident. Interviews with facility staff revealed that the missing debit card and financial discrepancies were not promptly reported or investigated. Staff members failed to follow up on the resident's concerns or assist in obtaining necessary bank statements for benefit applications. The lack of timely intervention and reporting allowed the misappropriation to go undetected for an extended period, impacting the residents involved.
Failure to Notify Provider and Emergency Contact of Resident Transfers
Penalty
Summary
The facility failed to notify the resident's provider and emergency contact (EC) of changes in condition and hospital transfers for one resident with multiple serious diagnoses, including acute respiratory failure, heart failure, kidney disease, and esophageal cancer. Record review showed that on several occasions, the resident was transferred to the hospital due to shortness of breath and low hemoglobin levels, as identified by the dialysis provider, but there was no documentation that the provider or EC was informed of these transfers. Additionally, when the resident developed moderate swelling in the left arm and was transferred to the hospital per provider's order, there was again no indication that the EC was notified. Interview with a registered nurse confirmed that the EC had not been contacted during these events, as required, and this was corroborated by the absence of documentation in the daily care notes. The deficiency was noted as a repeat from a previous survey, indicating a continued failure to communicate significant changes in the resident's condition and hospital transfers to both the provider and the EC.
Failure to Revise and Update Resident Care Plans as Required
Penalty
Summary
The facility failed to ensure that care plans were revised and updated as required for six residents. Specifically, staff did not conduct quarterly care plan meetings for five residents in accordance with their admission and Minimum Data Set (MDS) assessments. Record reviews showed that the intervals between care plan meetings exceeded the required quarterly schedule for these residents, as confirmed by the Director of Nursing. The care plan meetings were not held within the expected 90-day timeframe, resulting in lapses in the review and updating of residents' care plans. Additionally, the facility did not update the care plan for a resident with a colostomy to reflect that the resident and the resident's family were providing colostomy care. Physician orders indicated that nursing staff were responsible for changing the colostomy wafer and pouch, but interviews with the resident's family and the Assistant Director of Nursing confirmed that the family frequently performed this care. This information was not included in the resident's care plan, despite staff awareness of the family's involvement.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed that staff failed to maintain sanitary food storage and handling practices in the kitchen and dry storage areas. Specifically, three large cheese pizzas and thirteen containers of chocolate chip cookies were found in storage without labels or dates. A large cardboard box of green beans was left open to air in the kitchen freezer, and several food items, including a package of tortillas, two packages of hamburger buns, and one package of hotdog buns, were stored past their expiration dates. During an interview, the Dietary Manager confirmed these findings and acknowledged that all food items should be labeled, dated, stored appropriately, and not expired. These deficiencies were identified as affecting all 117 residents listed on the facility's census at the time of the survey.
Failure to Assess and Document Resident's Skin Issue
Penalty
Summary
A resident with a sore and redness near the right eye reported pain and uncertainty about the cause, stating he may have scratched himself due to lack of hand control. The resident indicated he had informed someone about the wound, but was unsure who, and stated that nursing staff had not examined the area as of the interview date. The Director of Nursing was unaware of any skin issue for this resident and stated that such concerns should be reported to a nurse and documented on shower sheets. The Assistant Director of Nursing later confirmed the presence of a scratch near the resident's eye, noting that if a Certified Nurse Aide observed it, it should have been documented and reported. Review of the resident's shower sheets over multiple dates revealed no documentation of the skin issue, indicating a lack of assessment, documentation, and treatment for the resident's skin condition.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
A nurse entered a resident's bathroom without announcing herself while the resident was being assisted with a shower by a CNA. The resident, who was cognitively intact with a BIMS score of 15 and required substantial to maximal assistance for bathing, reported feeling disrespected and that her privacy was violated by the nurse's unannounced entry. The incident was corroborated by the resident's roommate, who confirmed that the nurse entered without warning and that the resident was visibly upset by the event. Interviews with facility staff, including the ADON, CNA, and DON, revealed that the facility's expectation is for staff to knock, wait for permission, and announce themselves before entering a room where personal care is being provided. The resident is known to be vocal about her preferences and typically only allows certain staff to assist with her care. Despite these established protocols and the resident's clear communication of her preferences, the nurse failed to follow the expected procedure, resulting in a breach of the resident's right to privacy and dignity during personal care.
Failure to Complete Timely Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a timely assessment for a resident who experienced a significant change in condition and was hospitalized. The resident, who had multiple diagnoses including paranoid schizophrenia, psychotic disorder with delusions, chronic kidney disease, diabetes, and dysphagia, exhibited symptoms such as needing help holding his head up, reduced strength in arms and legs, and slurred speech. Following these symptoms, the nurse practitioner was contacted and the resident was transferred to the hospital for evaluation. Upon the resident's return from the hospital, record review showed that the facility completed a Minimum Data Set (MDS) Discharge Return Anticipated assessment at the time of transfer and an MDS Entry assessment upon return. However, the facility did not complete a significant change in status assessment within 14 days of the event, as required. During interviews, the DON and MDS coordinator expressed uncertainty about whether an MDS change of condition assessment was necessary in this situation.
Failure to Notify Provider and Emergency Contact After Resident Fall on Blood Thinner
Penalty
Summary
The facility failed to notify the appropriate medical provider and the resident's emergency contact after an unwitnessed fall involving a resident who was prescribed a blood thinner. Documentation showed that the resident experienced a fall in the early morning hours, but there was no evidence that the on-call provider or the resident's emergency contact was notified immediately, as required. The only progress note regarding the fall was recorded later in the day, and the emergency contact reported learning about the incident only after a family member visited the facility. The resident had a history of a previous pelvic fracture and was taking Warfarin, a blood thinner, at the time of the fall. Following the incident, the resident was monitored with post-fall observations and neurological evaluations, which did not initially indicate cognitive decline or pain. However, the resident's daughter later noticed a bruise on the resident's temple and reported increased lethargy and rib pain, which led her to call emergency services for hospital evaluation. Imaging at the hospital revealed new rib fractures, though no acute life-threatening injuries were found. Interviews with facility staff, including nurses, the nurse practitioner, the assistant director of nursing, and the director of nursing, confirmed that the provider was not notified of the fall as required, especially given the resident's use of anticoagulant medication. The medical doctor also stated he was not contacted, despite documentation suggesting otherwise. Staff acknowledged that both the provider and the emergency contact should have been notified immediately after the fall.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide care that meets professional standards by administering oxygen therapy to a resident without obtaining a physician's order. Record review showed that the resident was admitted and subsequently discharged to the hospital, and during their stay, oxygen was administered on multiple occasions at varying flow rates, as documented in the electronic health record. Despite this repeated administration, there was no corresponding physician order authorizing the use of oxygen for the resident. Interviews with the resident's emergency contact and a CNA confirmed that the resident was observed wearing oxygen while at the facility. The Director of Nursing also verified, after reviewing the resident's records, that there were no physician orders for oxygen use, even though the resident received oxygen frequently. This lack of physician authorization for oxygen therapy constitutes a failure to meet professional standards of quality care.
Failure to Honor Resident Dietary Preferences and Restrictions
Penalty
Summary
A resident with documented dietary restrictions and preferences, including an inability to eat vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms, was repeatedly served these items despite clear instructions on her meal ticket. During an interview, the resident reported that she continued to receive foods she could not eat. Observation of her lunch plate confirmed the presence of mashed potatoes, which she had not eaten. Staff interviews and record reviews corroborated that the resident's dietary preferences and restrictions were not being followed, as her meal ticket clearly indicated the foods to avoid.
Inadequate Grievance Investigation and Resolution
Penalty
Summary
The facility failed to conduct a thorough investigation and adequately resolve a grievance filed by a resident. The resident, who is legally blind, reported issues with receiving cold and unappetizing meals, finding hair in his food, and experiencing delays in receiving assistance from CNAs for brief changes. The Social Services Director (SSD) only partially investigated the grievance, focusing solely on the temperature of the resident's food. The SSD did not take the temperature of the food but assumed it was warm based on visual cues. The SSD also failed to address the other concerns raised by the resident, such as the presence of hair in the food and the lack of timely assistance from CNAs. The resident expressed dissatisfaction with the resolution of his grievance, indicating that the meals remained mostly cold and that the other issues were not investigated. The Administrator acknowledged that the grievance was not investigated appropriately for each allegation and that it should not have been documented as resolved until the resident was satisfied. This lack of comprehensive investigation and resolution could lead to a decrease in the resident's quality of life, as the facility did not adequately consider or address the resident's needs.
Failure to Conduct Timely Care Plan Meetings for Residents
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents, resulting in a deficiency. Resident #35 was admitted to the facility and had their last care plan meeting on 07/24/24, with no subsequent meetings documented. During an interview, the resident could not recall having a recent care plan meeting, and the Social Services Director (SSD) confirmed that a quarterly care plan meeting was overdue. Similarly, Resident #90 was admitted and had their last care plan meeting on 07/16/24, with no further meetings documented. The resident expressed a desire for a care plan meeting, and the SSD acknowledged that a meeting was required but had not occurred. This lack of timely care plan meetings indicates a failure to update and address the residents' care needs as required.
Failure to Communicate Critical Lab Results and Ensure Medication Availability
Penalty
Summary
The facility failed to meet professional standards for two residents by not ensuring timely communication of critical lab results and availability of prescribed medications. For one resident, who had multiple diagnoses including diabetes and chronic kidney disease, the facility did not convey critical lab results to the medical provider in a timely manner. The resident vomited dark brown emesis, prompting an immediate order for a complete blood count (CBC). Although the lab results, indicating a critical hemoglobin level, were available on the same day, the provider was not informed until the following day, delaying necessary medical intervention. In another instance, a resident did not receive their prescribed medication, Eliquis, due to its unavailability during a medication pass. The nurse responsible did not check the facility's Pyxis system for the medication or notify the provider about its unavailability. The Director of Nursing confirmed that the medication should have been available in the Pyxis and that staff should have taken steps to ensure the medication was administered as ordered.
High Medication Error Rate Due to Unavailable Medication
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 23.08% during a survey. This deficiency was identified through observations, interviews, and record reviews involving two residents. Registered Nurse (RN) #2 administered medications to Resident #118, including Amlodipine, Aspirin, and Atorvastatin, as per the physician's orders dated 12/12/24. However, during the administration to Resident #122, RN #2 failed to provide Eliquis, a medication prescribed to treat and prevent blood clots, because it was not available, despite being ordered for daily administration at 7:00 am. The Assistant Director of Nursing (ADON) #1 confirmed that medications should be administered within one hour before or after the scheduled time, and any deviation from this schedule would be considered late. The failure to administer Eliquis as ordered contributed to the high medication error rate. The report highlights the facility's inability to ensure the availability and timely administration of prescribed medications, which is crucial for maintaining the residents' health and safety.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a safe and appetizing temperature for four residents, leading to a deficiency in meal quality. Residents reported that their food was often served cold, both in their rooms and in the dining room, despite having informed the staff about the issue. Observations confirmed that food items on the steam table were not maintained at safe temperatures, with several items measured well below the required 135 degrees Fahrenheit. The steam table was identified as broken, which contributed to the inability to keep food at the appropriate temperature. Interviews with residents and staff, including a cook and a registered dietitian, confirmed the issue of cold food being served. One resident had filed a grievance about the cold food, expressing dissatisfaction with the meal temperatures. The administrator acknowledged the problem and stated that dietary staff had been instructed not to serve cold food from the steam table, but the issue persisted, indicating a failure in maintaining food safety standards and resident satisfaction.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for two residents. On December 19, 2024, at 8:14 am, a Registered Nurse (RN) did not wash his hands before, during, or after administering medications to two residents. The RN drew and poured medications into cups, administered them to the residents, and returned to the medication cart without performing hand hygiene. During an interview, the RN admitted to not washing his hands and acknowledged that he should have used the hand wash stations available in the resident rooms. On December 23, 2024, the Director of Nursing (DON) confirmed that staff are expected to wash their hands before and after administering medications to residents. This failure to follow infection control practices has the potential to spread infectious diseases between residents.
Failure to Assist Resident with Personal Purchases
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not assisting with purchases that reflected the resident's interests. The resident, who was admitted to the facility on an unspecified date, expressed a preference for activities such as watching TV, painting, reading, and using a computer. The care plan, dated January 23, 2024, indicated that staff should ensure the resident had materials for these activities, including painting supplies. However, during an interview on December 17, 2024, the resident reported being unable to purchase painting materials and winter clothes, as the previous Social Services Director (SSD) who assisted with these purchases had left the facility. The resident confirmed asking facility staff for help multiple times without receiving assistance, and noted the absence of family support. The facility administrator acknowledged that the resident should have been assisted with online purchases but was not, following the departure of the previous SSD.
Failure to Provide Vegan Diet for Resident
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, specifically a vegan diet, leading to a deficiency in providing appropriate meals. The resident, identified as R #225, was admitted with a regular diet order, but had informed the admitting nurse and several CNAs of her vegan dietary preference. Despite this, she continued to receive meals that did not align with her vegan diet, such as country fried steak and eggs with bacon. The resident resorted to having family and friends bring her vegan food, as the facility did not provide meals that met her dietary needs. The deficiency was further compounded by the absence of the Kitchen Manager, who was responsible for interviewing residents about their dietary preferences. The Registered Dietitian confirmed that no interview was conducted for R #225, and the staff continued to deliver meals based on the initial regular diet order. The lack of communication and follow-up on the resident's dietary needs resulted in her not receiving the appropriate vegan meals, as evidenced by the uneaten portions of her meal trays.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by a physician for a resident during random dining observations. The resident was prescribed a regular pureed diet, which is a texture-modified diet requiring no chewing, as indicated in the Dietary Census List and the resident's care plan. However, during a lunch observation, the resident was served pureed mashed potatoes, pureed carrots, and mechanical soft meatloaf, which requires some chewing. This was contrary to the resident's dietary meal ticket, which specified a therapeutic diet. A dietary staff member confirmed that the resident should have been served pureed meatloaf instead of mechanical soft meatloaf, indicating a failure to adhere to the prescribed diet.
Failure to Provide ADL Assistance to Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident, specifically in the areas of toileting and brief changes. This deficiency was identified when the resident's daughter, who is the Power of Attorney, reviewed footage from an in-room camera she had installed to monitor her mother's care. The video from 05/28/24 showed that no staff entered the resident's room throughout the day to provide care or check on her brief, despite the resident's inability to manage these tasks independently. Upon being informed of the situation, the facility's administration conducted an investigation. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the Certified Nurses Aide (CNA) assigned to the resident did not provide care on the specified day. The CNA admitted to not checking on the resident during her 12-hour shift, as the resident did not use her call light. The facility's Administrator took immediate action by relieving the CNA of her duties and ensuring she did not return to the facility.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure wounds for a resident, identified as R #128. Upon admission, the staff did not identify existing pressure ulcers, and subsequent weekly skin checks lacked proper staging and measurement of the wounds. The resident's pressure ulcers, initially noted on the sacrum and heels, were not adequately monitored, leading to a significant deterioration in the condition of the wounds. The facility's records revealed inconsistencies and omissions in documenting the resident's wound care and progress. Despite the presence of a community-acquired pressure ulcer, the staff failed to update treatment orders or notify the physician of the worsening condition in a timely manner. The resident's care plan indicated a risk for further skin injuries, yet the staff did not report signs of skin breakdown as required. The resident's pressure ulcer eventually progressed to a stage 4, with measurements indicating a decline, but this was not communicated effectively to the physician assistant (PA) or documented in the medical records. Interviews with facility staff, including the LPN, PA, ADON, and DON, highlighted a lack of communication and documentation regarding the resident's deteriorating condition. The PA was not informed of the worsening pressure ulcer until it had significantly declined, and the ADON could not provide evidence of notifying the PA earlier. The resident's condition ultimately required hospitalization, where they were diagnosed with a sacrococcygeal decubitus ulcer and osteomyelitis, leading to hospice care. The failure to timely identify, monitor, and communicate the resident's pressure ulcer condition contributed to the deficiency noted in the report.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, leading to potential contamination and foodborne illness risks. Observations revealed that the ice machines in various locations contained black and white substances with slime, indicating improper maintenance and cleaning. The dietary staff and maintenance staff were responsible for maintaining these machines, but there was a lack of awareness and communication regarding the contamination. Additionally, staff failed to perform proper hand hygiene and glove changes, leading to cross-contamination during food preparation. Dietary aides were observed handling food and kitchen items without washing hands or changing gloves between tasks, despite being trained on proper procedures. The facility also failed to protect clean dishes and plastic ware from contamination. Observations showed that plastic ware and lids were left uncovered, exposing them to potential contaminants as staff moved around the kitchen. Clean dishes were stored improperly, with some being wet-stacked, which could lead to bacterial growth. Furthermore, pureed food was not served at the appropriate temperatures, and staff did not remove improperly heated food from service, posing a risk of foodborne pathogens. Additional deficiencies included improper storage of staff food with resident food, inadequate use of hair restraints, and failure to label and date open food items. The kitchen environment was not maintained in a clean and sanitary manner, with visible dirt, spills, and debris in various areas. The facility's failure to follow proper sanitization procedures for dishes and food preparation sinks further contributed to the risk of contamination. These deficiencies had the potential to affect all residents consuming food from the facility's kitchens.
Failure to Update and Communicate Care Plan Changes
Penalty
Summary
The facility failed to update and revise care plans for three residents, leading to deficiencies in addressing their care needs. Resident #45's care plan did not document the required assistance for Activities of Daily Living (ADL), despite the Minimum Data Set (MDS) indicating a need for partial to moderate assistance. The Director of Nursing (DON) acknowledged that the care plan should have included these requirements. Similarly, Resident #60's care plan lacked documentation of ADL requirements and activity preferences, even though the MDS showed a need for substantial and maximal assistance. Both the Activities Director and the DON confirmed these omissions. For Resident #320, the facility failed to inform the Power of Attorney (POA) about changes in the care plan, specifically regarding new behavioral symptoms. The care plan initially included behavioral symptoms, but the POA was not notified of any updates or escalations in behavior, as confirmed by both the POA and the DON. This lack of communication and documentation could result in the residents' care needs not being adequately addressed.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in offering and providing baths and showers as per their care plans. Resident #45, who required partial/moderate assistance, was supposed to receive a bath or shower twice a week, but records showed inconsistencies in meeting this schedule. Observations and interviews revealed that the resident often received only one shower a week due to staff shortages, which left the resident feeling unclean. Staff, including a CNA and LPN, confirmed that the resident did not frequently refuse showers and acknowledged the failure to meet the scheduled bathing routine. Similarly, Resident #60, who required substantial/maximal assistance, was also not provided with the scheduled two baths or showers per week. Despite changes in the bathing schedule, records indicated that the resident did not consistently receive the required number of baths or showers. Interviews with the resident and staff confirmed that the resident was not refusing showers and that the staff was aware of the deficiency in providing the necessary care. The DON acknowledged that both residents were not given the appropriate number of baths or showers as per their schedules.
Medication Mismanagement: Pills Left Unattended on Bedside Table
Penalty
Summary
The facility failed to ensure that medications were not left unattended on a resident's bedside table, which posed a potential risk to the health of all residents on the 400 hall. During an observation, a total of 12 pills were found on a resident's bedside table, including Ranolazine, Mucus Relief DM, and Pantoprazole Sodium. The resident was unaware of the presence of these medications or how long they had been there. A review of the resident's physician orders and medication administration records confirmed that these medications were prescribed and administered regularly. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and a Certified Medication Aide, revealed that the medications were left on the bedside table by a Certified Medication Aide. The staff acknowledged that medications should not be left unattended and that they are required to observe residents taking their medications during administration. This oversight in medication management could lead to residents taking incorrect medications or dosages, although the report does not specify any actual harm that occurred.
Failure to Follow Nutritionally Calculated Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that staff followed nutritionally calculated recipes for pureed diets, which were approved by the Registered Dietician (RD). This deficiency was observed during meal preparation, where staff did not measure ingredients accurately or follow the provided recipes. For instance, a staff member added an unmeasured amount of chicken-flavored powder to pre-measured vegetables and did not have a recipe for the pureed vegetables. Similarly, another staff member guessed the amount of gravy added to pureed chicken, deviating from the recipe that specified precise measurements. The Dietary Manager (DM) admitted to not following the recipe for Texas toast due to time constraints and a lack of awareness of the recipe's existence. The DM was responsible for overseeing the kitchen operations, including the preparation of pureed foods, and was expected to ensure staff followed the recipes. The RD confirmed that menus and recipes are reviewed every six months and expected dietary staff to adhere to them. The failure to follow these recipes had the potential to affect the nutritional requirements of all six residents who consumed pureed meals.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices for four residents, as observed during a survey. For two residents, nasal cannulas used for oxygen delivery were not labeled with the date of change, contrary to the physician's orders and facility protocol, which required changing and labeling every shift. Observations revealed that the oxygen tubing was left on the floor, and staff interviews confirmed the absence of date labels, indicating a lapse in following the established procedures for infection control. Additionally, the facility did not store CPAP equipment and nebulizers appropriately for two other residents. The CPAP masks and nebulizers were found unsealed and placed on nightstands with other personal items, rather than being stored in clean bags as required. Staff interviews, including those with CNAs, LPNs, and the Director of Nursing, confirmed the improper storage and acknowledged the failure to comply with the facility's infection control policies. These deficiencies could potentially lead to the spread of infections among residents.
Failure to Provide Required Eating Assistance Device
Penalty
Summary
The facility failed to provide necessary assistance devices for a resident, identified as R #13, who required a sippy cup for meals. This deficiency was identified through observation, record review, and interview. The resident's Annual Nutritional Assessment, completed by a Registered Dietitian, recommended the use of a sippy cup, and there was a physician's order dated 04/01/24 for a sippy cup to be provided with all meals. Additionally, the resident's meal ticket for 07/18/24 included a note for a sippy cup. However, during a lunch observation on 07/18/24, the resident was served a meal without the sippy cup. An interview with an LPN confirmed that the sippy cup was not provided, as the LPN stated she had never seen one with the resident's meal.
Failure to Honor Resident's Rights in Medication Administration
Penalty
Summary
The facility failed to ensure the rights of a resident when it administered medication to reduce the resident's sexual feelings and desires without proper consent. The resident, who had vascular dementia, psychotic disturbance, mood disturbance, and cognitive communication deficit, was observed engaging in consensual sexual activity with another resident. Despite the psychologist's assessment that the resident had the capacity to consent to sexual activity, the Nurse Practitioner and Medical Director decided to increase the resident's escitalopram dosage to dampen his libido, citing concerns about his decisional capacity and inability to recall the incident. The resident's daily care notes documented an incident where the resident was found engaging in sexual activity with another male resident in the open doorway of a room. The CNA who observed the incident reported that the engagement appeared consensual and assisted the resident in pulling up his pants. The psychologist noted that residents of long-term care have the right to sexual expression and did not recommend libido dampening medication. However, the Nurse Practitioner and Medical Director disagreed, leading to an increase in the resident's medication dosage. Interviews with facility staff, including the CNA, NP, psychologist, and Medical Director, revealed differing opinions on the resident's capacity to consent to sexual activity. The Medical Director ultimately decided to implement the NP's recommendation to increase the resident's escitalopram dosage, despite the psychologist's assessment. This decision was based on the belief that the medication would help manage the resident's sexual drive, but it failed to honor the resident's right to self-determination and communication.
Excessive Dose of Anti-Depressant Administered Without Adequate Indications
Penalty
Summary
The facility administered an anti-depressant medication, escitalopram, to a resident at an excessive dose without adequate indications for its use. The resident, who has multiple diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and cognitive communication deficit, was initially prescribed 5 mg of escitalopram daily. Following an incident where the resident was found engaging in sexual activity with another male resident, the Nurse Practitioner recommended increasing the dose to 10 mg to dampen the resident's libido, despite no increase in the resident's level of depression being documented. The Medical Director reviewed and accepted the Nurse Practitioner's recommendation to increase the escitalopram dosage, citing that anti-depressants can reduce sexual drive. However, the Medical Director acknowledged that the prescribed anti-depressant was for depression and not for managing sexual behavior. The resident did not have a past history of sexual acting out, and both the Medical Director and the Nurse Practitioner stated that the resident was unable to make informed decisions about sexual interactions or other care needs, yet the resident was his own decision maker without a guardian. The Director of Nursing confirmed that the resident was pleasant and interactive, with no recent changes in behavior indicating a change in mental status or increased depression. The deficiency lies in the facility's decision to increase the resident's anti-depressant dosage without adequate indications for its use, potentially leading to overmedication and associated side effects.
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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