Sandia Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 2216 Lester Drive Ne, Albuquerque, New Mexico 87112
- CMS Provider Number
- 325032
- Inspections on file
- 37
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Sandia Ridge Center during CMS and state inspections, most recent first.
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.
Staff failed to keep medication and treatment carts locked and attended on three hallways, resulting in unsecured medications and supplies. A medication cart on one unit was observed unlocked and unattended outside a room, and an LPN confirmed it was her cart and that it should have been locked. Another medication cart on a different unit was also found unlocked and unattended, which a CNA confirmed. A treatment cart on a third unit was similarly observed unlocked and unattended outside a room, and an RN acknowledged it should have been locked before leaving the area. The DON stated that medication and treatment carts are expected to be locked at all times when not in use or when nurses are away from them.
Staff failed to protect residents' PHI by leaving multiple types of documents containing identifiable information, including CNA shower lists, face sheets, and vital sign lists, unattended and exposed on treatment/medication carts in hallways. These documents were observed on several occasions on different units, visible to anyone passing by. An LPN, an RN, and a CMA each confirmed that the documents were left exposed and acknowledged that resident-identifiable information and PHI should not be left unattended.
A resident admitted for orthopedic aftercare following surgical amputation, with a history of kidney transplant and difficulty walking, arrived from the hospital with discharge orders for non–weight-bearing status to the right lower extremity and a requirement for a private room due to immunocompromised status from immunosuppressive medication. These orders were not transcribed into the facility’s physician orders, and thus non–weight-bearing and isolation precautions were not implemented. The DON reported that admission orders from the hospital were expected to be reviewed and clarified before arrival, but acknowledged that the admission nurse did not complete this review, leading to the omission.
A resident admitted with recent surgical amputation, kidney transplant status, mobility limitations, osteomyelitis, and multiple high‑risk medications (including azathioprine, Eliquis, gabapentin, insulin, and IV antibiotics for VRE and other infections) did not have a complete baseline care plan developed within 48 hours of admission. Record review showed the baseline care plan failed to address pain management, antibiotic use, weight‑bearing status, anticoagulant use, and hypoglycemia related to insulin therapy. The DON confirmed in interview that these areas were omitted and that the baseline care plan was not completed as required within the first 48 hours after admission.
A resident receiving hospice care did not have physician orders for hospice services in the medical record. Review of the chart showed signed hospice documents and confirmation from the Social Services Director that the resident had been admitted to a hospice agency, but no corresponding physician order was found. The DON acknowledged that physician orders for hospice should have been present and confirmed they were missing from the resident’s record.
A resident who required assistance with ADLs was not provided with scheduled showers as outlined in the care plan, which called for twice-weekly baths/showers and as-needed bathing. Review of the EHR showed that over multiple weeks the resident received or was offered significantly fewer showers than scheduled, including a period with no documented shower offers at all. The UM confirmed that the showers did not occur as scheduled and stated that CNAs are expected to provide and document showers or refusals in the EHR after each opportunity.
Surveyors observed a drink and snack cart with a pitcher of milk placed on ice that was not labeled or dated, which a CNA confirmed. In the kitchen, two dietary aides were seen preparing food without required beard restraints. The Dietary Manager acknowledged that all items leaving the kitchen are expected to be labeled and dated and confirmed that the aides were not wearing beard restraints as required.
Surveyors found that restrooms in four resident rooms had vinyl baseboard coverings in disrepair, including multiple gaps and holes of varying lengths around the walls and behind toilets. In one room, gaps of about six and seven inches extended along both sides of the wall and behind the toilet, while other rooms had smaller gaps and holes ranging from about one to four inches near and beside the toilets. The MD confirmed the presence of these gaps and holes in all four identified rooms and acknowledged that the vinyl baseboards required immediate repair to prevent insects and pests from entering.
A resident with a G-tube, indwelling catheter, unhealed pressure ulcers, and ongoing wound care orders required Enhanced Barrier Precautions (EBP), but staff failed to post EBP signage at the room entrance during multiple observations. The resident had active orders for enteral feeding, catheter management, and daily wound care. The ADM and DON both acknowledged that the resident met criteria for EBP and that signage is used to inform staff of required precautions, yet no such signage was present, demonstrating a failure to implement the infection prevention and control program.
The facility failed to ensure meals were palatable and served at an appetizing temperature, as multiple residents reported that their food was consistently or often cold, sometimes arriving after long delays and no longer warm enough to enjoy. One resident described the food as horrible and stopped requesting reheating because it did not improve the temperature, while another reported inconsistent meal temperatures. During a lunch observation, plates for two residents were cool to the touch. The Dietary District Manager acknowledged awareness of complaints about cold food, and the Administrator confirmed awareness of ongoing food temperature problems despite the use of plate bases and warmers.
Multiple residents did not receive scheduled assistance with ADLs, including bathing, showering, and nail care. Documentation and interviews confirmed that residents were not consistently offered or given baths/showers as scheduled, and requests for nail care were not addressed in a timely manner. Staff and family members observed lapses in personal hygiene, and records were incomplete or missing for required care activities.
A resident with dementia and a history of traumatic brain injury was found outside the facility and had a Wander Guard device placed on their wheelchair without a provider order or care plan documentation. The device was applied before any order was obtained, and staff confirmed that nurses could place such devices without provider authorization or documentation of elopement risk.
A resident with dementia, a history of traumatic brain injury, and poor safety awareness was ordered to have a Wander Guard elopement device, but the care plan did not document the elopement risk or the device order. This omission was confirmed by the Assistant DON during review.
Nursing staff did not follow protocol to preserve the scene of a suspicious death, as they removed a bag from a resident's head, cleaned and moved the body, and discarded evidence before contacting OMI and police. This action was not in accordance with professional standards or state requirements, as confirmed by facility leadership and the OMI investigator.
A resident with dementia, traumatic brain injury, and a history of homelessness was able to leave the facility unsupervised after removing a Wander Guard device, despite staff being aware of repeated elopement attempts and the resident's poor safety awareness. The care plan did not address elopement risk or include necessary interventions, and staff failed to provide adequate supervision, resulting in the resident being missing for over 24 hours.
A resident with acute infective endocarditis and bacteremia did not receive prescribed IV antibiotics on time due to the facility's failure to ensure timely delivery from the pharmacy. The resident's medication administration record showed missed doses of Ampicillin and Ceftriaxone, leading to a hospital transfer. The ADON confirmed the importance of timely administration to maintain therapeutic levels.
A resident with dementia and coordination issues experienced a mechanical fall, resulting in fractures and hospital admission. The facility failed to investigate or report the incident to the state agency within the required timeframe, as the Administrator was unaware of the fall and injuries. This oversight left the resident at risk of further harm.
A facility failed to investigate and report an injury of unknown origin for a resident with multiple diagnoses, including dementia and fractures. The resident was transferred to a hospital for worsening edema, where it was revealed that a fall had occurred, but no fall was reported within the facility. Interviews with staff indicated a lack of awareness and failure to conduct an investigation or report the incident to the state agency.
A resident with multiple chronic conditions sustained bruises on both hands after a Wound Care Nurse mistakenly believed the resident had her cell phone and forcefully took it, despite the resident's refusal. The incident was witnessed by the ADON, who described the interaction as inappropriate. The resident was very upset by the incident, and the nurse later returned the phone and apologized.
The facility failed to document the daily temperature of a refrigerator used to store resident snacks in the 100 unit, potentially affecting all 23 residents in that unit. During an observation, it was noted that the refrigerator contained food items and snacks for residents, but a review of the temperature log revealed that staff did not document the refrigerator's temperature on several dates. A CNA confirmed the lapse in documentation.
A resident's family reported finding the resident in a very wet and smelly brief, but the grievance was not documented or investigated. Interviews with the DON and ADM confirmed that the incident should have been reported and investigated, but it was not.
The facility failed to keep medications in original packaging, store expired supplies separately, and consistently record refrigerator temperatures for medications and vaccines. Expired medications were also found mixed with unexpired ones. The DON confirmed these lapses in protocol.
The facility failed to treat residents with respect and dignity by not ensuring staff knocked on residents' bedroom doors before entering. A CNA and an RN entered rooms without knocking, and both confirmed they should have knocked. The DON stated that staff are expected to knock, announce their intention to enter, and wait for permission before entering a resident's room.
The facility failed to invite residents to care plan meetings, as evidenced by two residents who were not notified or invited to their care plan conferences. Staff interviews revealed systemic issues, including lack of documentation and verbal notifications without proper records.
The facility staff did not report an incident where a resident was found unresponsive with drug paraphernalia. Narcan was administered, and the resident responded but refused ER transport. The Administrator did not report the incident, believing it was not a drug overdose.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease and dependence on renal dialysis. The care plan lacked critical details such as dialysis fistula care, monitoring for infections, and specific goals and interventions. The deficiency was confirmed by the DON.
The facility failed to inform a resident or their representative about the risks and benefits of buspirone, a psychotropic medication prescribed for anxiety and behaviors. The resident's medical records lacked documentation of informed consent, and the DON confirmed that a signed consent form was missing.
A resident, who was independent and had intact cognition, wanted to shower daily and independently, but the facility's policy required staff presence during showers. The staff were unable to accommodate her preferred shower times, leading to her dissatisfaction and a complaint to Social Services. The facility's policy and staffing constraints prevented her from showering according to her preference.
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.
Unlocked and Unattended Medication and Treatment Carts on Multiple Units
Penalty
Summary
The facility failed to ensure medications and biologicals were properly stored and secured when multiple medication and treatment carts were left unlocked and unattended on the 200, 300, and 400 hallways. On 03/17/26 at 9:38 a.m., a medication cart on the 300 unit was observed unlocked and unattended outside a resident room, and at 9:40 a.m. an LPN confirmed the cart was hers, acknowledged it was unlocked and unattended, and stated she should have locked it. At 9:42 a.m., a medication cart on the 400 unit was observed unlocked and unattended outside a resident room, and at 9:43 a.m. a CNA confirmed the cart was left in that condition. At 9:49 a.m., a treatment cart on the 200 unit was observed unlocked and unattended outside a resident room, and at 9:50 a.m. an RN confirmed the treatment cart was left unlocked and unattended and stated the nurse should have locked it prior to leaving the area. On 03/19/26 at 11:07 a.m., the DON stated that medication carts should always be locked when nurses are away from the cart and further stated it is an expectation for nurses to keep medication and treatment carts locked at all times when not in use.
Unattended PHI Documents Left Exposed on Treatment Carts
Penalty
Summary
The facility failed to safeguard residents' personal health information by leaving documents containing resident-identifiable information unattended and exposed on treatment/medication carts in hallways. On 03/17/26 at 9:40 a.m., a stack of CNA shower lists with complete resident information was observed lying on top of a treatment cart outside a resident room, unattended and visible to the public. At 9:42 a.m., an LPN confirmed that the CNA shower list was exposed to public view and acknowledged that resident-identifiable information should not be left unattended. On 03/19/26 at 8:38 a.m., a stack of patient face sheets with resident information was observed on top of a treatment cart outside a resident room, again left unattended and exposed to public view. At 8:40 a.m., an RN confirmed that a face sheet was left exposed and unattended and stated that personal health information should not be left unattended. On 03/18/26 at 8:46 a.m., a stack of resident vital sign lists containing resident information was observed on top of a treatment cart on the 400 wing, unattended and visible. At 8:52 a.m., a CMA confirmed that the resident vitals list was exposed to public view and unattended, and acknowledged that resident-identifiable information should not be left unattended.
Failure to Implement Hospital Discharge Orders for Weight-Bearing and Isolation Status
Penalty
Summary
The facility failed to ensure that physician orders from a transferring hospital regarding weight-bearing status and isolation needs were accurately transferred and implemented for one admitted resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status requiring immunosuppressive medication, and difficulty in walking. Hospital discharge orders dated 10/09/25 included a non–weight-bearing order for the right lower extremity and a requirement for a private room due to immunocompromised status related to the kidney transplant. Review of the resident’s physician orders at the facility showed that the non–weight-bearing status for the right lower leg and the isolation precautions related to immunosuppressive medication were not present. In an interview, the DON stated that the resident should have had these physician orders in place per the hospital discharge instructions and that her expectation was that all hospital admission orders be reviewed and clarified before the resident’s arrival. The DON confirmed that the admission nurse did not review and clarify these admission orders, and as a result, they were not implemented.
Failure to Complete Comprehensive Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop a complete baseline care plan within 48 hours of admission for one resident. The resident was admitted and later discharged within a few days, with documented diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status, difficulty walking, reduced mobility, and acute osteomyelitis of the right ankle and foot. Physician orders at admission included multiple high‑risk medications and treatments: azathioprine for immunosuppression, Eliquis as an anticoagulant, gabapentin for neuropathic pain, insulin for diabetes, and IV antibiotics (linezolid for VRE and meropenem). These orders and diagnoses established several immediate clinical needs at the time of admission. Record review showed that the baseline care plan dated the day after admission did not address key areas related to the resident’s immediate needs, specifically pain management, antibiotic use, weight‑bearing status, anticoagulant use, and hypoglycemia related to insulin therapy. In an interview, the DON confirmed that the baseline care plan failed to include these elements and acknowledged that the baseline care plan should be completed within the first 48 hours of admission, which did not occur as required. This omission formed the basis of the cited deficiency.
Failure to Obtain Physician Orders for Hospice Services
Penalty
Summary
The facility failed to obtain physician orders for hospice services for one resident receiving hospice care. Record review showed that this resident was admitted to the facility on an unspecified date, and review of the physician orders did not reveal any order for admission to hospice services. The resident’s electronic health record contained signed hospice documents dated 02/24/26, and the Social Services Director stated in an interview that the resident was admitted to a named hospice agency on that same date. In a separate interview, the DON confirmed that the resident should have had physician orders for hospice services and acknowledged that no such orders were available or present in the resident’s medical record. This deficiency was identified for one of three residents reviewed for hospice services, based on the absence of required physician orders despite documentation and staff statements confirming the resident’s enrollment in hospice care.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers for one resident who required assistance with activities of daily living (ADLs). Record review showed that this resident was admitted on 10/13/25 and discharged on 01/07/26, with a care plan indicating the resident should be offered a bath/shower twice weekly on Tuesdays and Thursdays and as needed. Review of the electronic health record (EHR) from 09/01/25 through 11/30/25 revealed that from 10/13/25 through 10/31/25, the resident was offered or received only 2 baths/showers out of 6 scheduled opportunities, and from 11/01/25 through 11/30/25, the resident was offered or received 0 baths/showers out of 2 scheduled opportunities. During an interview on 03/19/26 at 11:54 a.m., the Unit Manager confirmed that the showers for this resident did not occur as scheduled. The Unit Manager also stated that the facility’s expectation is for CNAs to shower residents on their scheduled days and document in the EHR after each opportunity, whether the shower was given, missed, or refused. The deficient practice was noted as likely to result in residents feeling dirty and neglected, resulting in isolation.
Failure to Label Milk and Use Beard Restraints During Food Preparation
Penalty
Summary
Surveyors identified deficiencies in food storage and handling practices when a drink and snack cart outside a resident room was observed with an unlabeled and undated pitcher of milk sitting on a bucket of ice. A CNA confirmed that the milk on the cart was not labeled or dated. In a separate observation in the facility kitchen, two kitchen aides were seen preparing food without wearing beard restraints. During an interview, the Dietary Manager stated that his expectation is that kitchen staff label and date every item leaving the kitchen, which did not occur in this instance, and confirmed that the two kitchen aides were not wearing beard restraints as required when in the kitchen. No specific resident medical histories or conditions were mentioned in relation to these deficiencies.
Damaged Vinyl Baseboards in Multiple Resident Restrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident restrooms in good repair and free from damage, specifically related to vinyl baseboard coverings in four resident rooms on the 200, 300, and 400 halls. During random room observations, surveyors noted that in one room, the vinyl baseboard covering was in disrepair with gaps measuring approximately six inches along the bottom left portion of the wall, extending through the corner and continuing behind the toilet, and an additional gap of approximately seven inches along the right side of the wall, also continuing behind the toilet. In another room, the vinyl baseboard covering had a hole measuring approximately one and a half inches in the corner to the right of the toilet and another hole of approximately two inches on the wall to the left of the toilet. Further observations showed that in a third room, the vinyl baseboard covering was in disrepair with a gap of approximately two inches on the wall to the left of the toilet and a one-inch gap on the wall to the right of the toilet. In a fourth room, a gap of approximately four inches in length was present on the wall to the left of the toilet. During an interview, the Maintenance Director confirmed the presence of gaps and holes in the vinyl baseboard coverings in the restrooms of rooms 210, 305, 307, and 405 and acknowledged that the vinyl baseboards should be repaired immediately to prevent insects and pests from entering through the gaps and holes.
Failure to Post Enhanced Barrier Precautions Signage for High-Risk Resident
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not posting required Enhanced Barrier Precautions (EBP) signage for a resident who met criteria for these precautions. The resident was admitted on 12/17/25 and had diagnoses and conditions including gastronomy status, an indwelling catheter, a swallowing disorder requiring a feeding tube, unhealed pressure ulcers, and a continued risk for developing pressure ulcers requiring wound care. Physician orders dated 03/07/26 included enteral feeding every day and night shift, as-needed indwelling catheter changes when occluded or leaking, and daily wound care for pressure ulcers with specific cleansing and dressing instructions. During multiple observations on 03/09/26 and 03/10/26, the resident was noted to have an indwelling Foley catheter and a feeding tube, and there was no EBP signage posted at the entrance to the room indicating that enhanced precautions were required. The Administrator stated that the resident required EBP because of the indwelling catheter and feeding tube and confirmed that there was no sign posted, acknowledging that there should have been one. The DON also stated that the resident required EBP for direct care and that signage is used to inform staff about required precautions and the type of precautions needed. These observations and interviews showed that the facility did not implement appropriate EBP signage for this resident as part of its infection prevention and control program.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable and served at an appetizing temperature for all six residents reviewed, with the potential to affect all 128 residents in the facility. Multiple residents reported that their meals were consistently or often cold when they were supposed to be hot. One resident stated they ate only what they could tolerate because the food often arrived too cold to enjoy. Another resident reported that room trays sometimes took a long time to reach the rooms, and others stated their meals were often not warm enough or were already cold by the time the tray reached them. One resident described the food as horrible and said they no longer asked to have it warmed up because it had not helped in the past, and another resident reported that meal temperatures were inconsistent, with some meals arriving cold and others not. During observation of a lunch meal tray delivery to one unit, the plates for two of the reviewed residents were noted to be cool to the touch, supporting the residents’ reports of inadequate food temperatures. In interviews, the Dietary District Manager acknowledged being aware of residents’ complaints about cold food served at the facility. The Administrator stated that the facility used plate bases and plate warmers to help keep hall tray meals warm and acknowledged awareness of a problem with food temperatures. These interviews and observations demonstrate that the issue of cold meals was known to facility leadership and dietary management while residents continued to receive meals that were not served at an appetizing temperature.
Failure to Provide Scheduled ADL Assistance and Personal Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, specifically in the areas of bathing, showering, and nail care. Documentation revealed that one resident, who had physical and cognitive impairments and was scheduled for baths or showers three times a week, did not consistently receive the scheduled number of baths or showers over several months. Interviews with staff and the resident's power of attorney confirmed that the resident was not offered or given enough baths/showers as scheduled, and family members observed the resident to be visibly dirty and with a foul odor during visits. Staff also confirmed that all baths/showers and refusals should be documented, but shower sheets were missing for the relevant timeframes. Another resident reported not receiving hair or nail care unless provided by family, and documentation showed a lack of records regarding bathing, with only one refusal documented out of multiple opportunities. Staff interviews confirmed that residents should be offered showers multiple times per week, regardless of hospice status, but this was not consistently done. A third resident and their family reported missed scheduled baths, and documentation supported that only one shower was recorded for the month, despite a schedule of three per week. The DON confirmed that documentation showed insufficient offers or provision of baths and showers for these residents. A fourth resident requested nail care, stating that staff would not allow her to have a nail clipper and that her nails were getting too long. Staff interviews revealed that the request had not been communicated to the appropriate personnel, and the resident continued to wait for nail care. The DON stated that the expectation is for staff to provide nail care when requested and to communicate a timeframe if it cannot be done immediately. The lack of timely and documented ADL assistance, including bathing and nail care, was confirmed through interviews, record reviews, and direct resident and family reports.
Unauthorized Use of Physical Restraint Without Provider Order
Penalty
Summary
A resident with diagnoses including dementia, a history of traumatic brain injury, and homelessness was admitted to the facility and was not identified as an elopement risk according to the Elopement Risk Evaluation. Despite this, a daily care note documented that the resident was found in the parking lot and subsequently had a Wander Guard device placed on their wheelchair. The resident expressed a desire to leave the facility and stated they did not want to be there. A provider order for the Wander Guard was not entered until several days after the device was placed. The resident's care plan did not include documentation regarding elopement risk or the use of the Wander Guard. The Assistant Director of Nursing confirmed that the Wander Guard was placed prior to the provider order and acknowledged that nurses had access to and could place Wander Guards without a provider order. There was no documentation explaining who placed the device or the rationale for its use prior to the order.
Failure to Revise Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan for one resident who was identified as an elopement risk. Record review showed that the resident had diagnoses including dementia, a history of traumatic brain injury, and homelessness, and required assistance with personal care. A provider order was present for staff to place a Wander Guard elopement device on the resident due to poor safety awareness. However, the resident's care plan did not include documentation of the elopement risk or the order for the Wander Guard. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that there was no care plan addressing the resident's elopement risk or the use of the Wander Guard device.
Failure to Preserve Scene of Suspicious Death Prior to Notification of Authorities
Penalty
Summary
Nursing staff failed to maintain the scene of a suspicious death in accordance with professional standards and state requirements. A resident with multiple fractures and an aortic aneurysm was found unresponsive in his room with a bag over his head and tied at the neck. The nurse observed no signs of life, removed the bag, and pronounced the resident dead. The nurse then notified the health provider, facility administration, and the Office of Medical Investigator (OMI) after the body had already been disturbed. Staff proceeded to clean and move the body, remove the Foley catheter, and change the sheets before the arrival of police or OMI. Upon arrival, police found the body covered with a sheet and learned that staff had discarded the bag and string, and had already cleaned the scene. The Assistant Director of Nursing confirmed that the expectation was for staff to contact OMI before moving or disturbing the body, which was not followed in this case. The OMI investigator also stated that the nurse was instructed to leave the scene untouched and contact police immediately, but this was not done prior to the scene being altered.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for a resident identified as being at risk for elopement. The resident, who had diagnoses including dementia, a history of traumatic brain injury, and homelessness, exhibited impaired cognitive function and poor safety awareness. Despite multiple documented incidents of the resident attempting to leave the facility and expressing a desire to do so, the care plan did not address elopement risk or include interventions such as the use of a Wander Guard or increased supervision. Although a provider order was eventually entered for a Wander Guard, the resident refused to wear it and was able to remove it without staff intervention. On the day of the incident, the resident was last seen after lunch and was later found to be missing, with staff unable to locate him after searching the facility and surrounding areas. The resident had exited the building by pressing a button that unlocked the front door, after having cut off the Wander Guard device, which prevented the alarm from sounding. Staff were aware of the resident's elopement risk and previous attempts to leave, but failed to ensure adequate supervision or monitoring to prevent the resident from leaving the facility unsupervised.
Failure to Administer IV Antibiotics on Time
Penalty
Summary
The facility failed to ensure that a resident received prescribed intravenous (IV) medications on time, as per professional standards of practice. The resident was admitted with multiple diagnoses, including acute infective endocarditis and bacteremia, and was prescribed Ampicillin and Ceftriaxone to be administered intravenously. However, the facility did not provide and administer these antibiotics as ordered by the prescriber. The medication administration record indicated that several doses of Ampicillin and Ceftriaxone were not administered due to the medications not being delivered by the pharmacy. The resident's daily notes revealed multiple entries indicating that the IV solutions were awaiting delivery, and the family expressed concern about the delay in administration. The resident was eventually transferred to a hospital due to not receiving the prescribed antibiotics, as confirmed by the hospital emergency room care note. The Assistant Director of Nursing confirmed that the IV antibiotics were ordered but not available for multiple doses, emphasizing the importance of timely administration to maintain therapeutic levels, especially given the resident's diagnosis of endocarditis.
Failure to Report Resident Injury of Unknown Source
Penalty
Summary
The facility failed to report a resident's injury of unknown source to the State Agency within the required 24-hour timeframe. The resident, identified as R #4, was admitted to the facility with multiple diagnoses, including pain in the left hip, dementia, and lack of coordination. After a mechanical fall, the resident was admitted to the hospital with a fracture of the left femur and patella. Despite the resident's hospital admission and subsequent return to the facility with surgical incisions, the facility did not conduct an investigation or report the incident to the state agency. The Administrator admitted to being unaware of the fall and the extent of the resident's injuries. Consequently, no investigation was conducted, and no initial or follow-up reports were submitted to the state agency. This oversight left the resident at risk of further injuries, as the facility did not take the necessary steps to address and report the incident as required by regulations.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and report within five working days an injury of unknown origin for a resident. The resident was admitted with multiple diagnoses, including pain in the left hip, dementia, and lack of coordination. After being readmitted to the facility with new diagnoses of fractures in the left femur and patella, the resident was transferred to a hospital due to worsening edema. Hospital records indicated that the resident had fallen a few days prior, resulting in left hip pain, but there was no record of a fall reported within the facility. Interviews with the Assistant Director of Nursing and the Administrator revealed that there was no awareness of the fall or the extent of the resident's injuries. The Administrator acknowledged that no investigation was conducted, and no report was submitted to the state agency as required. This lack of action prevented the state agency from appropriately triaging the allegation for further investigation.
Resident Sustains Bruises Due to Staff Misconduct
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where a resident sustained bruises on both hands. The resident, who had multiple diagnoses including Type 2 diabetes mellitus with a foot ulcer, chronic respiratory failure with hypoxia, adjustment disorder with mixed anxiety and depressed mood, and chronic systolic heart failure, was involved in an altercation with the Wound Care Nurse (WCN). The incident occurred when the WCN mistakenly believed the resident had her cell phone and attempted to retrieve it by force, despite the resident's refusal to hand it over. This resulted in a struggle, during which the resident sustained bruises on both hands. The incident was witnessed by the Assistant Director of Nursing (ADON), who observed the WCN forcefully taking the phone from the resident, causing a loud and noticeable disturbance in the dining area. The resident expressed being very upset by the incident, and the ADON described the interaction as inappropriate. The Licensed Practical Nurse (LPN) who documented the incident noted the bruises on the resident's hands and confirmed the WCN's actions. The WCN later realized the phone was not hers and returned it to the resident, apologizing for the mistake.
Failure to Document Refrigerator Temperatures
Penalty
Summary
The facility failed to document the daily temperature of a refrigerator used to store resident snacks in the 100 unit, potentially affecting all 23 residents in that unit. During an observation on 07/23/24, it was noted that the refrigerator, located in the dining area, contained food items and snacks for residents. A temperature log was attached to the front of the refrigerator. However, a review of the log for July 2024 revealed that staff did not document the refrigerator's temperature from 07/05/24 through 07/07/24 and from 07/13/24 through 07/23/24. During an interview on 07/23/24, CNA #1 confirmed that the refrigerator contained resident snacks and foods and that staff were expected to monitor and record the refrigerator temperature on the log. CNA #1 verified that the temperature was not recorded on the specified dates, indicating a lapse in the facility's procedure for ensuring proper food storage.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to recognize, investigate, and respond to a grievance reported by the family of a resident. The resident, who was admitted with multiple diagnoses including sepsis, altered mental status, disorientation, and difficulty walking, was found by his wife and daughter in a very wet and smelly brief. This incident was reported to the evening nurse on duty, but no grievance report was filed for the month of April 2024 regarding this issue. Interviews with the resident's daughter, the Director of Nursing (DON), and the Administrator (ADM) revealed that the incident was not reported to the DON or the ADM, and no investigation was conducted. The DON and ADM both confirmed that the incident should have been reported and investigated as a grievance, but it was not. This failure to address the grievance is likely to result in residents feeling that their concerns do not matter and their rights are not being honored.
Medication and Supply Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were kept in their original packaging, as observed on the 300 medication cart where a small medication cup was filled with unlabelled round pills. The Certified Medication Aide (CMA) confirmed that the pills were Tylenol 325 mg, which had been removed from their original container for convenience. The Director of Nursing (DON) acknowledged that staff should not take medication out of the original container and store it in the top of the medication cart. Additionally, expired supplies were found in the medication room, including lubricating jelly, ultrasound gel, syringes, IV start kits, and central line trays, which the DON confirmed should have been removed by nursing managers responsible for checking expiration dates. The facility also failed to consistently record refrigerator temperatures for both medication and vaccine storage. Temperature logs for the medication refrigerator showed multiple instances where temperatures were not documented, and the refrigerator contained insulin medications. Similarly, the vaccine refrigerator logs had missing temperature entries. The DON confirmed that staff were expected to fill out these logs daily. Furthermore, expired medications were found mixed with unexpired medications in the 500 medication cart, including a gemfibrozil tablet that had expired. The DON stated that nursing staff were supposed to check their medication carts for expired medications at least once a month, but this had not been done effectively.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to treat residents with respect and dignity by not ensuring staff knocked on residents' bedroom doors before entering. For Resident #22, a Certified Nursing Assistant (CNA) entered the room twice without knocking, and the CNA confirmed she should have knocked. For Resident #74, a Registered Nurse (RN) entered the room without knocking, and the resident expressed that it bothered her when staff did not knock. The RN confirmed that staff should knock and wait for permission before entering. The Director of Nursing (DON) stated that staff are expected to knock, announce their intention to enter, and wait for permission before entering a resident's room.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents or their representatives were invited to care plan meetings, as evidenced by the cases of two residents. For Resident #48, a review of progress notes from January 1, 2024, to April 9, 2024, revealed no documentation of a care conference or an invitation to a care plan meeting. During an interview, Resident #48 stated that he used to attend care plan conferences but was no longer invited. Similarly, for Resident #78, medical records indicated no documentation of a care conference or an invitation in the last three months. Resident #78 stated she was unaware of the care plan meetings because staff did not invite her and expressed a desire to attend them. Interviews with facility staff revealed systemic issues in the care planning process. The Administrator admitted that care plan meetings and conferences were not conducted as required, and notifications were not sent out because care plans were not scheduled. The Social Services Assistant mentioned that residents were notified by placing a letter on their bed but was unsure if copies were kept. The Social Services Director acknowledged being behind on care plans due to a lack of help and confirmed that notifications were not sent out because care plans were not completed. She also stated that Resident #78's care plan meetings were verbally communicated, and no sign-in sheet was maintained.
Failure to Report Unresponsive Resident Incident
Penalty
Summary
The facility staff failed to report an incident to the state agency where a resident was found unresponsive outside in a wheelchair with burnt foil, two straws, and a lighter at his feet. The staff administered two doses of Narcan, and the resident began to respond. Although the resident refused transport to the emergency room, the care plan was updated to address possible substance abuse, and a drug screen was conducted, which came back negative. The Administrator did not report the incident to the state agency, believing it was not a drug overdose since the resident's vitals normalized and the drug screen was negative.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with end-stage renal disease and dependence on renal dialysis. The care plan, dated 02/12/24, did not address critical aspects of dialysis care, including the dialysis fistula, care bruit, thrill, monitoring for signs and symptoms of infections, bleeding, and any abnormalities regarding the site. Additionally, the care plan lacked specific goals and interventions related to dialysis. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan did not include necessary dialysis-related information.
Failure to Inform and Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about the risks and benefits of psychotropic medications. Specifically, for one resident with diagnoses of dementia, major depressive disorder, and anxiety disorder, the staff did not provide information or obtain consent for the administration of buspirone, a medication prescribed for anxiety and behaviors. The resident's medical records lacked documentation that the resident or their representative was informed about why the medication was prescribed, what condition it treated, potential side effects, and alternative treatments. During an interview, the Director of Nursing (DON) confirmed that there should have been a signed consent form for the use of buspirone, which was not present in the resident's file. The existing consent form only covered psychotropic medications prescribed since 2021, and a new consent form should have been signed when buspirone was later prescribed. This oversight could result in residents potentially receiving unnecessary treatment or medication without being fully informed of the associated risks and benefits.
Failure to Accommodate Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident was bathed according to her preference. The resident, who was independent and had intact cognition, expressed a desire to shower every day and stated she could do so independently. However, the facility's policy required staff presence during showers, and the staff were unable to accommodate her preferred shower times, which were usually in the afternoon. The resident's care plan indicated she required minimal assistance for activities of daily living, including bathing, but the facility's policy did not allow her to shower independently, leading to her dissatisfaction and a complaint to Social Services. Interviews with the staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's policy was to have staff present for all showers, and the staff found it challenging to accommodate the resident's preferred shower times. The Director of Nursing acknowledged the resident's preference but felt that the resident needed supervision during showers for safety reasons. Despite the resident's ability to shower independently, the facility's policy and staffing constraints prevented her from showering according to her preference.
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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