Spring River Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roswell, New Mexico.
- Location
- 3200 Mission Arch Drive, Roswell, New Mexico 88201
- CMS Provider Number
- 325044
- Inspections on file
- 25
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Spring River Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident on hospice with osteomyelitis, ESBL, severe PUs, and other comorbidities had chosen a hospice physician to manage her care, but the facility refused to accept that physician’s orders for PU treatment. Instead, due to the lack of an in-house wound care nurse, the facility arranged repeated out-of-town wound clinic visits for wound care, as confirmed by the POA, the hospice executive director, and the ADON, and documented in multiple progress notes.
The facility failed to provide written notification with an explanation before changing a resident’s room. Review of the room change communication form showed that neither the resident nor the representative was informed in advance. The resident’s representative later reported arriving for a visit, finding the resident no longer in the original room, and having to ask staff where the resident had been moved.
A resident with multiple complex conditions, including osteomyelitis, ESBL infection, stage 4 sacral PU, and an attention and concentration deficit, experienced a 22% weight loss over several months while under facility care. The care plan required staff to assist with meals, monitor intake, and offer alternate food choices when less than 50% of a meal was consumed, yet documentation showed numerous days when the resident ate under 50% of all meals with no recorded alternatives offered. Observation showed the resident eating only a small portion of a meal without assistance, and staff removed the tray without assessing hunger or offering substitute food, demonstrating failure to follow the ordered nutritional interventions.
A resident with paraplegia, cellulitis, and diabetes was discharged without confirmation that home health services were arranged, despite physician orders and a care plan indicating the need for such services. Facility staff could not verify that the referral to the home health agency was sent or received, and the agency had no record of receiving the referral or admitting the resident.
Two residents with significant medical needs did not have access to a functioning call light system in their rooms, as confirmed by both staff and direct observation. The facility's policy requires working call lights or alternative communication devices, but these were not provided or maintained for the affected residents.
The facility failed to maintain complete and accurate medical records for two residents. One resident's records lacked documentation of a change of condition and the reason for hospital transfer due to shortness of breath. Another resident's records did not describe events leading to a change in condition and death, despite a hospice referral. The DON confirmed the absence of necessary documentation.
A resident with a complex medical history developed a fever, and the facility failed to notify the physician as required by the resident's care plan. Despite orders to contact the physician before administering acetaminophen for fever, nursing staff gave the medication without notification. Documentation confirmed the oversight, and interviews with the DON and medical director acknowledged the failure to follow physician orders.
A resident with dementia and other health issues was administered acetaminophen for a fever without notifying the physician, contrary to medical orders. The facility's staff documented the administration and effectiveness of the medication but failed to follow the order to contact the provider when the resident developed a fever. The medical director confirmed that the staff should have adhered to the physician's instructions.
The facility did not ensure that the consultant pharmacist's recommendations from monthly drug regimen reviews were reviewed by the physician. The DON and Administrator confirmed the lack of documentation and completion of these reviews before November 2024, potentially affecting all 96 residents.
The facility failed to provide adequate support staff for food and nutrition services, leading to delayed meal services. Observations showed meals were served significantly later than scheduled, causing frustration among residents. One resident vocalized and banged on the table due to delays, while another fell asleep waiting for assistance. The Administrator acknowledged the issue of late meal service.
The facility did not have a QAPI plan in place, affecting all 96 residents. The Administrator confirmed the absence of a QAPI plan, records, and monitoring system since July 2024. Despite a policy commitment to QAPI principles, the facility failed to implement these across care and service areas.
The facility failed to implement an effective infection prevention and control program, as observed by surveyors. A Unit Secretary entered rooms with special precautions without PPE, and PPE disposal containers were incorrectly placed outside rooms. The DON confirmed the absence of necessary documentation and program implementation due to previous management lapses.
The facility did not implement a comprehensive antibiotic stewardship program, affecting all 96 residents. The DON admitted to the lack of documentation for the program, which was not in place before November 2024. The facility's policy requires an ASP with protocols and monitoring, with the IP responsible for the program and the Administrator accountable for compliance.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented care needs. One resident's MDS inaccurately stated bedrails were not in use, another's was not updated after returning to the facility, and a third's incorrectly indicated dialysis treatment. These inaccuracies were confirmed by the DON.
The facility failed to complete comprehensive care plans for three residents, affecting the implementation of preventative measures. One resident's care plan omitted prescribed medications, another's lacked focus, goals, and interventions, and a third's did not include Foley Catheter care. The DON confirmed these deficiencies.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their care needs. One resident's plan lacked interventions for pain management, another's was incomplete for anti-depressant use, a third's did not reflect a left ankle fracture, and a fourth's was not updated for Foley Catheter use. The DON confirmed these omissions, indicating care plans were not updated as required.
A facility failed to provide proper Foley catheter care for a resident with chronic urinary issues, leading to a deficiency. The resident's catheter care orders were incomplete, lacking details such as catheter and balloon size, and necessary maintenance orders were not documented. The DON confirmed the oversight, highlighting the importance of proper documentation and care for residents with chronic conditions.
A medication error occurred when an RN mixed Guaifenesin and Lamotrigine in a single cup for a resident's feeding tube, contrary to the facility's policy requiring separate administration. This resulted in a medication error rate of 6.45%, exceeding the acceptable threshold.
The facility failed to ensure that medications and medical supplies in the North Medication Storage room were not expired. Observations revealed expired laxative enemas, Ibuprofen, and needless connectors. A registered nurse confirmed that these items should have been discarded.
The facility failed to ensure that two residents had completed and signed consent or refusal forms for the pneumococcal vaccine. One resident had not been offered the vaccine since 2019, and another resident's records lacked evidence of the vaccine being offered. The facility's policy requires offering the vaccine after education but does not specify the frequency.
The facility failed to offer COVID-19 vaccinations to three residents, as their EHRs showed no evidence of offers after their last vaccinations in 2021 and 2022. This was confirmed by the DON, despite the facility's policy requiring adherence to CDC guidelines for vaccination in LTC settings.
A facility failed to ensure a resident was free from unauthorized physical restraints, specifically bed rails, which were used without orders, consent, or documentation. The resident's records indicated a preference against bed rails, and the MDS assessment did not document their use. The DON confirmed the lack of authorization for the bed rails.
A resident with multiple health conditions, including MS and anxiety disorder, was found smoking in his room despite requiring supervision. The facility's care plan stated smoking materials should be kept at the nurses' station, but the resident had access to them, leading to unsupervised smoking. The facility had previously allowed residents to hold their smoking supplies, contributing to this deficiency.
A facility failed to monitor a resident for side effects of Clopidogrel Bisulfate and Trazadone, as confirmed by the DON. The resident was prescribed these medications for daily use, but the December 2024 medication administration record showed no monitoring for side effects, leading to a deficiency in medication management.
The facility did not post the required daily nurse staffing data, including the facility name, date, and hours worked by RNs, LPNs, and CNAs, as well as the resident census. This was observed at the main entrance, and a Medical Records staff member confirmed the omission.
The facility failed to monitor and address significant weight loss in four residents, leading to a deficiency in nutritional care. One resident lost 37.3 pounds in 41 days without proper monitoring or intervention, while another resident's weight dropped from 221.8 to 181.4 pounds over several months. Despite care plan goals, residents consistently consumed less than the targeted meal percentages, and the facility did not notify the nutritionist or physician about the weight loss. Interviews with staff revealed a lack of action in response to documented meal consumption and weight loss.
The facility failed to create comprehensive care plans for two residents, neglecting to address specific medical needs such as wound care, surgical aftercare, and significant weight loss. The DON confirmed these omissions, highlighting deficiencies in the care planning process.
The facility failed to provide necessary treatment and services for pressure ulcer care for two residents, leading to deficiencies in promoting healing and preventing new ulcers. One resident's ulcer was not measured or treated for over a month, while another developed an ulcer without documentation or treatment orders. The DON confirmed these lapses in care and documentation.
A resident experienced a significant weight loss of 24.8% over four months, which was not documented in the MDS assessment. The DON confirmed the oversight, acknowledging that the weight loss should have been recorded.
The facility failed to lock treatment and medication carts while unattended, risking unauthorized access to medical supplies and personal health information for all 103 residents. Observations revealed unlocked carts in front of the memory unit and on the 100 hall. Staff, including a CNA, LPN, and CMA, confirmed the carts should have been locked, and the DON acknowledged the requirement for securing them.
The facility failed to respect residents' rights, resulting in deficiencies in dignity and self-determination. A resident with a fracture was forced into a mechanical lift despite her refusal, causing distress and pain. Another resident was left in a soiled brief during meals due to a policy misunderstanding, leading to embarrassment. Additionally, a resident was yelled at by staff when trying to visit a friend, highlighting a lack of respect for resident rights.
Two residents with urinary catheters had incomplete care plans that failed to document the presence of the catheters and provide care instructions. The Director of Nursing confirmed these omissions, which could result in staff not understanding or implementing necessary treatments.
The facility failed to meet professional standards of care for three residents due to improper handling of catheters and medications. A resident's urinary catheter was pulled out during a transfer, and two residents lacked physician orders for catheter care. Additionally, a CMA was observed handling medication unsafely, leading to incomplete dosing.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. One CNA completed no training, another completed only two hours, and a third completed four hours. The Administrator confirmed these CNAs continued to work shifts without meeting training requirements.
A resident reported that a CNA yelled at him during a transfer, mishandling his catheter bag. The facility initially treated the incident as a customer service issue and only reported it to the State Survey Agency after the Ombudsman intervened, resulting in a delay in reporting the abuse allegation.
A resident with an indwelling urinary catheter reported verbal abuse by a CNA during a transfer. The facility's investigation was incomplete, lacking interviews with other residents and was submitted late to the State Agency. The Administrator partially substantiated the complaint but failed to meet the required investigation standards.
A facility failed to complete a baseline care plan for a resident admitted for surgical aftercare following toe removal. The resident, with diabetes and an infection, needed help with transfers and showering. The EHR lacked a care plan, which the DON confirmed should have been completed within 48 hours.
A resident with multiple diagnoses, including fractures and reduced mobility, had an indwelling urinary catheter that was accidentally pulled out during a transfer. The incident was not documented in the resident's EHR, as confirmed by the DON, indicating a failure to maintain complete and accurate medical records.
Failure to Honor Hospice Physician Choice for Wound Care Management
Penalty
Summary
The facility failed to honor a resident’s right to choose her attending physician by refusing to accept medical orders from her selected hospice physician for treatment of her pressure ulcers. The resident was admitted with multiple serious conditions, including osteomyelitis, ESBL, an unstageable right heel pressure ulcer, a stage 4 sacral pressure ulcer, hypertensive heart disease without heart failure, a cutaneous abscess of the buttock, and an attention and concentration deficit. Her record showed an order for admission to hospice care, and the resident’s Power of Attorney reported that hospice had been chosen so that the hospice physician would manage her care. However, the POA stated that the facility would not accept the hospice physician’s orders for pressure ulcer care and instead required the resident to attend appointments at an out-of-town wound clinic. The Hospice Executive Director confirmed that the facility contacted her to obtain permission to send the resident to a wound clinic because they did not have anyone in-house to provide the needed wound care. She explained that facility nurses are responsible for providing continuous wound care, with a hospice nurse providing wound care and measurements once weekly, yet the facility continued to send the resident to the wound clinic despite her being on hospice. The ADON stated that the resident was going to the wound clinic because the facility did not have a wound care nurse. Progress notes documented multiple dates on which the resident had out-of-town wound clinic appointments, demonstrating the facility’s ongoing reliance on the clinic rather than accepting and implementing the hospice physician’s orders for pressure ulcer management.
Failure to Provide Required Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notification with an explanation prior to a room change for one resident, identified as R #7. Record review of the facility’s communication form for room change notification dated 02/02/26 showed that neither R #7 nor her representative was informed in advance of the room change. During an interview on 03/24/26 at 1:47 p.m., R #7’s representative reported that the facility did not notify him before moving the resident to a new room and that, upon arriving for a visit, he went to the resident’s former room, found it empty, and had to ask facility staff where the resident had been moved. The report notes that, as a result of the facility’s failure to notify the resident and representative in writing, the resident and/or representative could experience confusion and frustration.
Failure to Follow Nutrition Care Plan Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident by not following the resident’s diet order and nutritional care plan, resulting in significant weight loss. The resident was admitted with multiple serious medical conditions, including osteomyelitis, ESBL infection, unstageable right heel PU, stage 4 sacral PU, hypertensive heart disease without heart failure, a cutaneous abscess of the buttock, and an attention and concentration deficit. The resident’s weight log showed a decline from 100.8 pounds to 78.6 pounds over six months, a 22.02% weight loss. The resident’s POA reported that the resident had lost about thirty pounds in the last few months. The resident’s care plan, revised on 01/08/26, directed staff to assist with meals using verbal and/or physical assistance, encourage the resident to come out of her room for meals, monitor intake at all meals, and offer alternate food choices if 50% of a meal was not consumed. The Nutrition – Amount Eaten log showed fourteen days in a one‑month period when the resident did not eat more than 50% of any meal that day. The electronic health record contained no documentation that alternative meal choices were offered on days when intake was less than 50%. During an observation, the resident received a breakfast tray and ate only a small portion of the meal without assistance, and staff later removed the tray without asking if she was still hungry or if she wanted an alternative food option.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were in place prior to the discharge of a resident who required ongoing care. The resident, who was admitted with paraplegia, cellulitis of the left lower limb, type 2 diabetes, and a need for assistance with personal care, had a documented goal to return to the community. The care plan and physician's note indicated that home health services were to be arranged upon discharge. However, the facility's records show that the referral to the home health agency (HHA) and the physician's orders were both dated on the day of discharge, with no confirmation that the HHA received or accepted the referral. Interviews with the facility's Social Services staff revealed that the resident initiated the discharge the day before leaving, and although the staff encouraged the resident to stay an additional day to allow time to arrange services, the resident agreed but was still discharged the following day. The Social Services staff could not provide evidence that the referral to the HHA was successfully sent or received. Additionally, the HHA representative confirmed that there were no records of the resident being admitted to their services or of receiving any orders for care.
Failure to Maintain Functioning Call Light System for Two Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents who required assistance. For the first resident, who had diagnoses including acute and chronic respiratory failure, major depressive disorder, epilepsy, generalized anxiety disorder, and required help with personal care, both the resident and a CNA observed that the call light in the resident's room did not activate the external light or provide any visible indication when pressed. This was confirmed during interviews and direct observation, with the CNA acknowledging the malfunction. For the second resident, who had Alzheimer's disease, dysphagia, and other medical conditions, a similar issue was observed. The CNA attempted to activate the call light in the resident's room, but it did not function. The CNA stated an intention to document and report the issue. The facility's policy requires that each resident have access to a working call light or alternative communication device in their room, bathroom, and bathing area, and that staff promptly report and address any malfunctions. However, these requirements were not met for the two residents reviewed.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, which could result in staff being unaware of the residents' daily care events, changes, and needs. For the first resident, the records lacked documentation of a change of condition, assessment of symptoms, or progress notes indicating the need for transfer due to shortness of breath. The resident's vital signs were last recorded without any indication of elevated temperatures or breathing issues, and there was no documentation explaining the reason for the ambulance call and subsequent hospital transfer. Interviews with staff confirmed the absence of necessary documentation and the expectation for records to be accurate and complete. For the second resident, the records did not include documentation or descriptions of events leading up to the resident's change in condition and subsequent death. The resident was referred to hospice services, but the electronic health record lacked details about the change from baseline condition. The Director of Nursing confirmed the absence of documentation and reiterated the expectation for complete and accurate records, especially when a resident experiences a change in condition.
Failure to Notify Physician of Resident's Fever
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who developed a fever. The resident, who had a complex medical history including unspecified dementia, muscle weakness, and a history of myocardial infarction, was admitted with physician orders for acetaminophen to be given as needed for pain or fever. However, a subsequent physician's recommendation specified that acetaminophen should only be given for pain, and the physician should be notified if a fever occurred. Despite this order, nursing staff administered acetaminophen to the resident on multiple occasions for a low-grade fever without notifying the physician. Documentation in the resident's electronic health record confirmed the administration of acetaminophen for fever and noted its effectiveness, but failed to record the physician's notification. Interviews with the Director of Nursing and the medical director confirmed that the physician should have been contacted when the resident developed a fever, indicating a lapse in following the physician's orders.
Failure to Follow Medical Orders and Notify Provider of Resident's Fever
Penalty
Summary
The facility failed to ensure quality care that meets professional standards for a resident when it did not follow a medical order and failed to notify the provider about changes in the resident's condition. The resident, who was admitted with multiple diagnoses including unspecified dementia, cognitive communication deficit, and muscle weakness, had a physician's order for acetaminophen to be given for pain only, with instructions to notify the physician if a fever occurred. Despite this, nursing staff administered acetaminophen for a low-grade fever without notifying the physician, as documented in the progress notes. The progress notes revealed that on multiple occasions, acetaminophen was administered to the resident for a fever, and the effectiveness was noted without documenting the new temperature or the reason for administration. The medical director confirmed that staff should have followed the physician's order and contacted the provider when the resident developed a fever. This failure to implement care orders and notify the provider about changes in the resident's vital signs could likely lead to staff and the physician being unaware of changes in the resident's condition, potentially worsening the resident's condition.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations from the monthly drug regimen reviews were reviewed and responded to by the physician. This deficiency was identified during interviews with the Director of Nursing (DON) and the Administrator. The DON admitted that there was no documentation available to show that medication regimen reviews were completed before November 2024, and although the pharmacist's printed recommendations could be provided, there was no evidence of physician review. The Administrator confirmed that the pharmacist's recommendations had not been completed prior to November 2024. This oversight has the potential to affect all 96 residents in the facility, as identified by the census provided by the Administrator.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support staff to effectively carry out the functions of the food and nutrition services, resulting in delayed meal services for residents. During an initial observation, the dining room doors were found closed and locked due to insufficient staffing. The facility's posted mealtimes were not adhered to, with meals being served significantly later than scheduled. For instance, lunch was served fifty-three minutes late, and breakfast was served forty-six minutes late. Interviews with residents revealed dissatisfaction with the delays, as one resident expressed frustration with the waiting times, and another resident adjusted her schedule due to the consistent lateness of meals. Further observations highlighted the impact of these delays on residents. During a dining observation, one resident began vocalizing and banging on the table due to the delay in meal service, while another resident fell asleep waiting for assistance with dinner. The Administrator acknowledged the issue of late meal service during an interview, indicating awareness of the problem. These findings demonstrate the facility's failure to meet the dietary needs of its residents in a timely manner due to inadequate staffing in the food and nutrition services department.
Failure to Implement and Maintain QAPI Plan
Penalty
Summary
The facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) Plan, which could potentially affect all 96 residents. During an interview, the Administrator admitted to not having a QAPI plan in place, lacking records of QAPI activities, and not having a QAPI monitoring system since July 2024. A review of the facility's policy for QAPI, dated October 2022, indicated a commitment to integrating QAPI principles across all care and service areas, including clinical care, quality of life, and patient choice. However, the absence of an active QAPI plan suggests a failure to adhere to these stated commitments.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to develop and implement an ongoing infection prevention and control program, which is crucial for preventing, recognizing, and controlling the onset and spread of infections. During observations, it was noted that signs indicating special contact and droplet precautions were present on the doorways of certain rooms. However, a Unit Secretary was observed entering these rooms without using the necessary personal protective equipment (PPE), which was available on carts outside the rooms. Additionally, containers for discarding used PPE were incorrectly placed outside the rooms, contrary to the facility's protocol that requires them to be inside the rooms for proper disposal before exiting. The Director of Nursing (DON) confirmed the absence of documentation for the infection prevention and control program, acknowledging that the program had not been developed or implemented prior to November 2024 due to the previous DON's failure to complete these duties. The facility's policy on Infection Control Outcome and Process Surveillance and Reporting outlines the responsibilities of the Infection Preventionist, including conducting regular outcome and process surveillance. However, the lack of documentation and adherence to these protocols indicates a significant lapse in infection control practices, potentially affecting all 96 residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is essential for optimizing infection treatment and minimizing adverse events from antibiotic use. This deficiency potentially affects all 96 residents in the facility. During an interview, the Director of Nursing (DON) admitted that there was no documentation available for the surveyors to review because the program had not been implemented before November 2024. The facility's policy, revised on 08/07/23, mandates the implementation of an Antibiotic Stewardship Program (ASP) with protocols and monitoring systems, with the Infection Preventionist (IP) responsible for the program and the Administrator ultimately accountable for compliance. The DON and Medical Director are tasked with executing ASP standards. The Administrator confirmed that the program was not in place prior to November 2024.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to inadequate services and support. For one resident, the MDS assessment inaccurately indicated that bedrails were not in use, despite a bed safety assessment showing they were safe to use with monitoring. Another resident's MDS assessment was not updated after their return to the facility, and it incorrectly stated that bedrails were not in use, even though the resident had expressed a preference against them. The Director of Nursing confirmed these inaccuracies during an interview. Additionally, a third resident's MDS assessment inaccurately documented that the resident was on dialysis, although there were no medical orders for dialysis, and the resident had never been on dialysis. This discrepancy was also confirmed by the Director of Nursing. These inaccuracies in the MDS assessments highlight a failure in the facility's processes to ensure that residents' assessments are current and reflective of their actual care needs and preferences.
Incomplete Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure the completion of comprehensive care plans for three residents, which could potentially affect the staff's ability to implement necessary preventative measures for the residents' health and well-being. For one resident, the care plan did not include the use of anticoagulant and psychotropic medications, despite the resident being prescribed and administered Clopidogrel Bisulfate and Trazadone. The Director of Nursing (DON) confirmed the omission of these medications from the care plan, acknowledging the requirement for their inclusion. Another resident's care plan was found to be incomplete, lacking focus, goals, and interventions, despite the resident having multiple diagnoses, including diabetes with complications, sepsis, insomnia, and depression. Additionally, a third resident's care plan failed to include Foley Catheter care, despite the resident having conditions such as a urinary tract infection and obstructive uropathy. The DON verified the incompleteness of the care plans for all three residents.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in addressing their care needs. For one resident, the care plan did not include necessary interventions for monitoring pain, non-pharmacological interventions, and the effectiveness of pain medication, despite an active order for Hydrocodone-Acetaminophen. Another resident's care plan was incomplete regarding anti-depressant medication, lacking individualized focus, goals, and interventions. Additionally, a resident with a left ankle fracture did not have their care plan revised to reflect this condition, and another resident's care plan was not updated to include the use of a Foley Catheter. Interviews with the Director of Nursing (DON) confirmed these omissions, indicating that the care plans were not updated as required for changes in conditions or on a quarterly basis. The failure to revise these care plans could result in the residents' care and needs not being adequately addressed. The report highlights the lack of timely updates and revisions to care plans, which are essential for ensuring appropriate and effective care for residents with changing medical conditions.
Deficient Foley Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate Foley catheter care for a resident, leading to a deficiency in maintaining sanitary conditions and potentially increasing the risk of urinary tract infections. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy, adult failure to thrive, and chronic urinary issues, had an indwelling catheter upon admission. However, the facility did not have complete orders for the catheter care, including the size of the catheter and balloon, and the necessary maintenance orders were not input into the computer system. During interviews, the Director of Nursing confirmed that the orders for the resident's indwelling urinary catheter were incomplete and not properly documented. The resident had a history of chronic UTIs and was a chronic catheter patient, which underscores the importance of proper catheter care. The lack of complete and accurate orders for catheter maintenance, such as changing the Foley catheter every 30 days, measuring and recording urine output, and checking for leaks, contributed to the deficiency identified by the surveyors.
Medication Administration Error via Feeding Tube
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by three medication errors occurring out of 31 opportunities, resulting in an error rate of 6.45%. This deficiency was observed during medication administration for one of the eight residents involved. Specifically, a Registered Nurse (RN) administered medications incorrectly via a feeding tube. The RN mixed Guaifenesin liquid with a crushed Lamotrigine capsule in a single cup, contrary to the facility's policy, which mandates that each medication be administered separately to avoid interaction and clumping. The incident involved a resident who was prescribed Guaifenesin syrup and Keppra solution for congestion and seizures, respectively. The RN, during an interview, indicated that she believed it was acceptable to mix medications based on their quantity. However, the facility's policy clearly states that medications should be administered separately through enteral tubes. The Director of Nursing confirmed that the expectation is for medications to be given separately, highlighting a deviation from established protocols during the administration process.
Expired Medications and Supplies Found in Storage Room
Penalty
Summary
The facility failed to ensure that all medications and medical supplies in the North Medication Storage room were not expired. During an observation, three boxes of laxative enemas and one bottle of opened Ibuprofen were found to be expired. Additionally, four needless connectors were also discovered to be expired. These findings were confirmed during an interview with a registered nurse, who acknowledged that the expired items should have been discarded.
Deficiency in Pneumococcal Vaccination Consent Process
Penalty
Summary
The facility failed to ensure that residents had completed and signed consent or refusal forms for the pneumococcal vaccine, leading to a deficiency in their immunization process. Specifically, two residents, identified as R #38 and R #74, were not offered the pneumococcal vaccination as required. For R #38, the Electronic Health Record (EHR) showed that the last pneumococcal vaccine was administered on 04/25/19, and there was no evidence of the vaccine being offered again since then, despite the Director of Nursing (DON) acknowledging that it should have been offered in April 2024. Similarly, R #74's EHR lacked evidence of the pneumococcal vaccine being offered, which was confirmed by the DON. The facility's policy, revised on 09/13/24, mandates that pneumococcal vaccinations be offered after residents receive education, but it does not specify the frequency of these offers.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to three residents, as identified in a review of their Electronic Health Records (EHRs). Resident #36's EHR showed that the last COVID-19 vaccination was received in October 2022, and there was no evidence of an offer for vaccination after that date. Similarly, Resident #38's EHR indicated the last vaccination was in November 2021, with no subsequent offer documented. Resident #74's EHR also lacked any evidence of an offer for the COVID-19 vaccination. These findings were confirmed during an interview with the Director of Nursing (DON). The facility's COVID-19 Vaccination policy, revised in February 2024, mandates offering vaccinations in line with CDC recommendations. The CDC advises that individuals in long-term care settings receive COVID-19 vaccinations, with specific guidelines for different age groups. Despite these guidelines, the facility did not adhere to its policy, as evidenced by the lack of documentation and offers for vaccination to the residents in question.
Unauthorized Use of Bed Rails as Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically bed rails, without proper authorization. This deficiency was identified for one resident, who was observed with small side rails at the head of the bed used for positioning. A review of the resident's physician orders revealed that the use of bed rails was not ordered, and the resident's consent form indicated a preference against bed rails. Additionally, the 5-day MDS assessment did not document the use of bed rails. During an interview, the Director of Nursing confirmed the absence of orders, consent, and MDS documentation for bed rail use, acknowledging that bed rails should not have been used under these circumstances.
Resident Smokes Unsupervised in Room Due to Lapse in Policy Enforcement
Penalty
Summary
The facility failed to prevent a resident from smoking in his room, which is a violation of the facility's smoking policy. The resident, who has multiple diagnoses including multiple sclerosis, anxiety disorder, and major depressive disorder, was admitted to the facility with a requirement for supervision while smoking. Despite this, the resident was found to be in possession of cigarettes and a lighter, which he kept in his bag, and admitted to smoking in his room. This was confirmed by a Certified Nursing Assistant (CNA) who stated that the resident was aware that smoking inside the building was not allowed but continued to do so. The facility's comprehensive care plan for the resident, revised in November 2024, clearly stated that the resident may smoke only with supervision and that smoking materials should be maintained at the nurses' station. However, during an interview with the Administrator, it was revealed that the facility had allowed residents to hold their smoking supplies instead of keeping them locked at the nurses' station. This lapse in policy enforcement led to the resident smoking unsupervised in his room, creating a potential hazard.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of medications for one resident, leading to a deficiency in medication management. The resident had physician orders for Clopidogrel Bisulfate, an anticoagulant, and Trazadone, a psychotropic medication, both prescribed for daily administration. However, a review of the resident's medication administration record for December 2024 showed that there was no monitoring for side effects associated with these medications. During an interview, the Director of Nursing confirmed that the facility did not monitor the resident for side effects of the anticoagulant and psychotropic medications, which constitutes a failure to address potential adverse effects and unnecessary medication use.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis at the beginning of each shift, which is a requirement. The missing information included the facility name, the current date, and the total number and actual hours worked by registered nurses, licensed practical nurses, certified nurse aides, and the resident census. This deficiency was observed on December 8, 2024, at 11:30 pm, when the nurse staffing data was not posted at the main entrance door. Additionally, during an interview at 1:35 pm on the same day, a Medical Records staff member confirmed that the nursing staff data was not posted.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in four residents, leading to a deficiency in nutritional care. Resident #1 experienced a drastic weight loss of 37.3 pounds over 41 days, which was not monitored or addressed despite recommendations from the nutritionist to obtain current weights. The resident's care plan included goals to consume more than 80% of meals and avoid significant weight changes, but these were not met, and the facility did not act on the documentation showing inadequate meal consumption. The resident was eventually hospitalized and passed away, with the family expressing concerns about the facility's care. Resident #2 also experienced significant weight loss, dropping from 221.8 pounds to 181.4 pounds over several months. Despite a care plan goal to consume more than 85% of meals, the resident consistently ate less than 25% of meals, and the facility failed to notify the nutritionist or physician about the weight loss. Similarly, Resident #3 lost 22.9% of their body weight over six months, with documentation showing they ate no more than 50% of meals. The facility did not verify the accuracy of the initial weight or address the weight loss in the care plan. Resident #4 lost 20 pounds in 38 days, equating to an 11.75% weight loss, yet their care plan did not include any goals or interventions related to this significant weight loss. The facility did not have medical orders to address the weight loss, and the Director of Clinical Operations confirmed that the weight loss was not planned. Interviews with facility staff, including the Director of Nursing, revealed a lack of action in response to the documented meal consumption and weight loss, contributing to the deficiency in nutritional care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident #1 was admitted with multiple diagnoses, including sepsis, muscle weakness, colostomy status, and surgical aftercare needs. Despite these conditions, the care plan for Resident #1 was not comprehensive, as it did not include necessary interventions for wound care, the abdominal surgical wound, foley catheter, or colostomy. The Director of Nursing confirmed that the care plan was not developed within the required timeframe and did not meet the facility's expectations for comprehensive care planning. Resident #4 was admitted with diagnoses including cerebral infarction, cellulitis, hyperlipidemia, and a laceration of the esophagus. Over a three-month period, Resident #4 experienced a significant weight loss of 11.43%, which was not addressed in the care plan. The Director of Nursing acknowledged that this significant weight loss should have been included in the care plan, indicating a failure to address the resident's nutritional needs adequately.
Deficiency in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcer care for two residents, leading to deficiencies in promoting healing and preventing new ulcers. Resident #1 was admitted with a pressure ulcer on the coccyx and a surgical wound, but the facility did not measure the ulcer or obtain timely wound care treatment orders for 34 days. The care plan intervention to provide wound treatment was also delayed by 35 days. The Director of Nursing (DON) confirmed that the orders and interventions were not implemented timely, and the wound's progress could not be assessed due to the lack of measurements. Resident #4 was admitted with intact skin but later developed a pressure ulcer, which was not documented in the baseline care plan. The facility failed to measure the ulcer or obtain medical orders for its care and treatment. The DON confirmed the absence of documentation regarding the ulcer's development and current status, as well as the lack of medical orders for its treatment. This lack of documentation and timely intervention contributed to the deficiency in pressure ulcer care for both residents.
Inaccurate MDS Assessment Due to Undocumented Weight Loss
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, which is a federally mandated assessment instrument. The resident in question was admitted with multiple diagnoses, including anemia, a thyroid nodule, type 2 diabetes with hyperglycemia, and an inflammatory disease of the prostate. A review of the resident's weight summary showed a significant weight loss of 24.8% over four months, from 207.8 pounds to 156.2 pounds. However, the MDS assessment did not document this significant weight loss. During an interview, the Director of Nursing confirmed the weight loss and acknowledged that it should have been captured in the MDS assessment, but it was not.
Unattended and Unlocked Treatment Carts
Penalty
Summary
The facility failed to ensure that all treatment and medication carts were locked while unattended, which had the potential to affect all 103 residents by allowing unauthorized access to medical supplies and personal health information. On multiple occasions, surveyors observed treatment carts located in front of the memory unit by the nurses' station and on the 100 hall being left unlocked and unattended. Certified Nursing Assistant (CNA) #5, Licensed Practical Nurse (LPN) #1, and Certified Medical Assistant (CMA) #3 confirmed that the carts should have been locked when not in use. The Director of Nursing (DON) also acknowledged that treatment carts should be secured while not in use.
Deficiencies in Resident Dignity and Rights
Penalty
Summary
The facility failed to honor the rights of residents to refuse care, resulting in a deficiency in resident dignity and self-determination. A resident with a humerus fracture was subjected to a mechanical lift for weighing purposes despite her explicit refusal and expression of pain. The resident, who was cognitively intact and preferred to manage her pain with Tylenol instead of prescription medication, was not informed of the procedure beforehand and was distressed by the experience. The facility's investigation confirmed the grievance, and the involved nurse's employment was terminated. Another resident experienced a lack of timely incontinence care, which compromised his dignity and comfort. The resident, who had multiple diagnoses including fractures and reduced mobility, was left in a soiled brief during meal times due to a misunderstanding of the facility's policy on cross-contamination. The resident expressed embarrassment and discomfort, and the Director of Nursing confirmed that the staff member involved misunderstood the policy and has since been retrained. Additionally, a resident was denied the right to visit other residents and was spoken to in an undignified manner. The resident, who was cognitively intact and actively engaged in various activities, was yelled at by a staff member when attempting to visit a friend in another unit. The incident was not reported by a witness due to fear of retaliation, and the Director of Nursing was unaware of such behavior occurring. These incidents collectively highlight a failure to respect and uphold the residents' rights to dignity and self-determination.
Deficient Care Planning for Residents with Urinary Catheters
Penalty
Summary
The facility failed to ensure that care plans were accurate and complete for two residents who had urinary catheters. For the first resident, the electronic health record indicated an admission date, and hospital discharge documentation revealed the placement of an indwelling urinary catheter. However, the care plan, last updated before the hospital visit, did not document the presence of the catheter or provide instructions for its care. This oversight was confirmed by the Director of Nursing during an interview, who acknowledged the absence of necessary documentation in the care plan. Similarly, the second resident's care plan also lacked documentation of a Foley catheter and instructions for its care, despite observations confirming the presence of the catheter. The Director of Nursing confirmed that the care plan did not reflect the resident's current medical needs, as it failed to include the catheter and care instructions. This deficiency in care planning could lead to staff not understanding or implementing the necessary treatments for the residents.
Deficiencies in Catheter Management and Medication Handling
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents, primarily due to improper handling of medical devices and medications. One resident experienced an incident where their indwelling urinary catheter was pulled out during a transfer from bed to wheelchair because the staff member forgot to unhook the catheter bag from the bed rail. This incident was not documented in the resident's Electronic Health Record (EHR), and the Director of Nursing (DON) confirmed the lack of documentation and could not identify the responsible Certified Nursing Assistant (CNA). Additionally, the facility did not obtain physician orders for the use and care of urinary catheters for two residents. Both residents had catheters placed during hospital visits, but their records lacked specific orders regarding catheter size, care, and maintenance. The care plans for these residents also did not document the presence of the catheters or provide instructions for their care. The DON acknowledged the absence of these orders and stated that it was expected for the nurse on duty to review hospital discharge documentation and contact the medical provider for necessary orders. Furthermore, a Certified Medical Assistant (CMA) was observed handling medications unsafely. The CMA prepared a Depakote Sprinkles medication capsule without wearing gloves and used her hand to sweep the medication powder off the cart and onto the floor, resulting in the resident not receiving the full dose. The DON confirmed that staff should wear gloves when handling medications, and the FDA guidelines state that if the contents of a capsule are spilled, a new capsule should be used.
Deficient CNA Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year. This deficiency was identified for three CNAs who were reviewed for compliance with the training requirements. CNA #1, hired on May 19, 2023, did not complete any training from the date of hire until September 5, 2024. The Administrator confirmed that CNA #1 continued to work shifts without completing any of the required training hours. CNA #2, hired on April 27, 2023, completed only two out of the required 12 hours of annual training by September 5, 2024. Similarly, CNA #3, hired on September 12, 2022, completed only four out of the required 12 hours of training from September 5, 2023, to September 5, 2024. The Administrator acknowledged that both CNAs continued to work shifts despite not meeting the training requirements. The Administrator stated an expectation for all CNAs to complete at least 12 hours of training per year.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Survey Agency. The incident involved a resident who reported that a Certified Nurse Assistant (CNA) yelled at him during a transfer from his bed to his wheelchair. The resident expressed concern that the CNA mishandled his catheter bag, potentially causing urine to re-enter his body, and reported the incident to the facility's Administrator on the day it occurred. However, the facility initially treated the incident as a customer service issue rather than a reportable abuse allegation. The facility's records indicate that the incident was reported to the State Survey Agency only after the Ombudsman brought it to their attention two days later. The Administrator confirmed that the report was submitted on that later date, acknowledging the delay. This failure to promptly report the allegation of verbal abuse as required by regulations put residents at risk of further abuse, as timely reporting is crucial for the protection and safety of residents.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation and document the findings regarding an allegation of abuse involving a resident. The resident, who had an indwelling urinary catheter, reported that a Certified Nurse Assistant (CNA) yelled at him during a transfer from his bed to his wheelchair. The resident expressed concern that the CNA mishandled the catheter bag, potentially causing urine to re-enter his body. The incident was reported to the facility's Administrator, who filed an Initial Incident Report with the State Agency. However, the follow-up Complaint Narrative Investigation Report was submitted late, and the investigation was deemed incomplete as it lacked documentation of observations or interviews with other residents to determine if similar incidents occurred. The Administrator admitted to partially substantiating the complaint based on the CNA's acknowledgment of a verbal argument but failed to interview other residents as part of the investigation. The follow-up report was submitted after the extended deadline, and the incident was labeled as unsubstantiated despite the CNA's admission. The Administrator acknowledged the expectation for thorough investigations to be completed and documented within the required timeframes, which was not met in this case.
Failure to Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed for a resident who was admitted for surgical aftercare following the removal of the small fifth toe on the left foot. The resident, who also has diabetes, high cholesterol, and an infection at the surgical site, reported needing assistance with transferring due to difficulty standing on the operated foot and required help with showering to prevent the wound from getting wet. Upon review, the resident's Electronic Health Record (EHR) did not contain a baseline care plan. The Director of Nursing confirmed the absence of the care plan and stated that it was expected to be completed within 48 hours of admission.
Incomplete Medical Records for Resident with Urinary Catheter Incident
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident, identified as R #3. The resident was admitted with multiple diagnoses, including fractures, pain, muscle weakness, and reduced mobility. According to the hospital discharge documentation, the resident had an indwelling urinary catheter placed. However, during an observation and interview, the resident reported that the catheter was accidentally pulled out during a transfer from bed to wheelchair because a staff member forgot to unhook the catheter bag from the bed rail. A review of the resident's Electronic Health Record (EHR) revealed that there was no incident note, nurse assessment, or explanation regarding the incident where the catheter was pulled out. The Director of Nursing confirmed that a nurse had replaced the catheter after the incident, but no documentation was found in the EHR. This lack of documentation represents a failure to maintain complete and accurate medical records, which could result in staff being unaware of the resident's care events and needs.
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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