Lovington Healthcare LLC

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice has the potential to affect all 58 residents as identified by the census provided by the Administrator on 11/25/25 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on observation and interview, the facility failed to ensure safe medication storage practices by not ensuring the medication cart was locked while unattended. This deficient practice has the potential to affect all 17 residents residing on the 300 hall as identified by the census provided by the Administrator on 11/25/25. If the facility does not ensure safe storage practices, then residents are at risk for unauthorized persons to have access to medications and adverse effects due to improper storage.

Inspectors wroteBased on observation and interview, the facility failed to ensure the hallway in the 300 hall was accessible for residents. This deficient practice is likely to affect all 17 residents residing on the 300 hall as identified on the resident census provided by the Administrator on 11/25/25. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to: 1. Follow safe food handling practices. 2. Properly label food items in the refrigerator. 3. Properly wear hair nets while in the kitchen. These deficient practices are likely to affect all 59 residents listed on the resident census list provided by the Administrator on 05/03/25 and are likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 5 (R #4, R #10, R #14, R #15, and R #28) of 5 (R #4, R #10, R #14, R #15, and R #28) residents reviewed when staff failed to: 1. Revise R #4's care plan to include information regarding mobility bars (safety devices designed to provide additional support and stability for people with limited mobility or balance), 2. Revise R #10's care plan to include information regarding positioning rails (rails used to assist in maintaining an object's location or position), 3. Revise R #14's care plan to remove information regarding positioning rails, 4. Revise R #15's care plan to remove information regarding pain interventions, 5. Revise R #28's care plan to remove information regarding psychotropic medication when the medication was discontinued. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the hallway in the 100 hall was accessible for residents. This deficient practice is likely to affect all 22 residents residing on the 100 hall as identified on the resident census provided by the Administrator on 05/03/25. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #36) of 2 (R #36 and R #40) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need.

Inspectors wroteBased on record review, observation, and interview, the facility failed to develop comprehensive a care plan for 1 (R #214) of 1 (R #214) resident reviewed when staff failed to develop a comprehensive care plan for oxygen therapy. This deficient practice is likely to result in staff not being aware of the residents' care needs and preferences, and residents not receiving the needed care.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #214) of 2 (R #23, and R #214) residents reviewed for respiratory care when the facility failed to ensure there was a physician order for use of oxygen. This deficient practice is likely to result in residents' care and needs not being met if staff are not aware of the indication for use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection prevention measures by not changing the oxygen tubing and cannula as ordered and having unbagged oxygen tubing and cannulas on the floor and on the back of wheelchairs for 2 (R #5 and R #21) of 3 (R #5, R #21, and R #35) residents reviewed. This deficient practice could likely cause the spread of infections and illnesses to the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodation for resident needs and preferences for 1 (R #1) of 1 (R #1) resident reviewed by not ensuring R #1 had access to his call light and was able to use call light. These deficient practices are likely to result in residents being unable to request assistance, such as needing help with activities of daily living (ADL's) or other acute distress.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure privacy during personal care for 1 (R #1) of 1 (R #1) residents reviewed for privacy when staff failed to pull the privacy curtain closed allowing his roommate full view of R #1's body parts. This deficient practice likely caused R #1 to feel ashamed and embarrassed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) residents when staff failed to: 1. Reposition R #1 in accordance with her care plan. 2. Communicate among staff and document when R #1 was repositioned. If the facility is not repositioning a resident per their care plan then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was accurate for 2 (R #1 and #2) of 2 (R #1 and #2) residents reviewed, when staff failed to document when a resident's tube feeding solution was changed and when a resident was provided hydration via a tube feed. This deficient practice is likely to result in staff confusion as to the services and treatment provided.

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain for 1 (R #3) of 1 (R #3) residents reviewed for pain when staff did not provide pain treatment. This deficient practice likely resulted in R #3 experiencing long periods of pain without sufficient relief.

Inspectors wroteBased on record review, observations, and interview the facility failed to: 1. Update the staffing sheets at the beginning of each shift or in a timely manner to reflect the staff working that day. This deficient practice could likely prevent the public as well at the 56 residents identified on the facility census list provided by the Administrator on 03/25/24 from having access to accurate, current, and previous staffing information.

Inspectors wroteBased on observation and interviews the facility failed to: 1. Ensure opened and accessed (has been used) insulin flex pens (an injectable diabetes medicine that helps control blood sugar levels. This medication helps the pancreas produce insulin more efficiently) were dated as to when they were initially opened by nursing staff. 2. Ensure all expired supplies were not kept with unexpired supplies. These deficient practices are likely to result in all 56 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication that may have lost their potency or effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety when staff failed to monitor the internal temperature of food to ensure it is safe for consumption. This failure could likely affect all 56 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 03/25/24) who eat food prepared in the kitchen.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures when: 1. Staff did not sanitize hands before or after medication administration to 3 (R #4, 37, 41) of 6 (R #4, 24, 31, 37, 41, 49) residents . 2. Staff did not sanitize blood pressure cuff after using on each 5 (R #4, 24, 31, 37, 49) of 6 (R #4, 24, 31, 37, 41, 49) residents. 3. Oxygen cannula (tubing that is placed in the nostrials that delivers oxygen) on the floor for 1 (R #54) of 1 (R #54) residents. If the facility does not adhere to infection control practices, then residents are likely to be at risk of infection or disease.

Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen equipment was in safe operating condition. This failure is likely to cause all residents to not receive meals as scheduled or served food at unappetizing temperatures.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, resident representatives, and Ombudsman received a written notice of transfer as soon as practicable for 1 (R #52) of 1 (R #52) residents sampled for being discharged . This deficient practice could likely result in the Ombudsman not knowing the reason for transfer or location to which the resident was discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain records of controlled substances (drugs subject to strict government control because they may cause addiction) on each medication cart. This deficient practice could cause the likelihood of controlled substances being diverted (a medical and legal concept including the transfer of any illegal prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on record review and interview, the facility failed to ensure they monitored for side effects of medication for 2 (R #56 and R #111 ) of 2 (R #56 and R #111) residents reviewed for unnecessary medications. If the facility is not adequately monitoring for the side effects of the medications prescribed to their residents then residents are likely to be at risk of adverse outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility staff) was accurate for 2 (R #25 and R #51) of 2 (R #25 and R #51) residents reviewed for MDS accuracy. This deficient practice could likely result in the facility not having an accurate assessment of resident's care needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed and implemented within 21 days of readmission for 1 (R #52) of 1 (R #52) residents reviewed for care plans. This deficient practice could likely result in the facility not providing appropriate care and treatment to meet the needs of the residents.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to provide services that meet professional standards when staff failed to: 1. Update diagnosis for the use of a medication ordered for R #47. 2. Follow physicians order regarding liquid consistencies for R #54 These deficient practices are likely to cause residents to aspirate if ordered liquid consistencies are not followed and residents are likely to receive the wrong use of medications if diagnosis are not updated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received dental services for 1 (R #46) of 1 (R #46) residents reviewed for dental care. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 1 (R #40) of 3 (R #40, R #46 and R #48) residents reviewed for food and drink were provided food and drink prepared in a form designed to meet the residents needs. This deficient practice is likely to negatively impact a resident not eating or having trouble with swallowing during mealtimes.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff offered COVID-19 (a highly infectious viral disease) vaccinations to 3 (R #7, R #50, and R #34) out of 5 (R #7, R #50, R #34, R #20, and R #46) residents reviewed for COVID-19 vaccines. This deficient practice could likely result in residents at risk for exposure to COVID-19 related infections.

Inspectors wrotePast Non-Compliance Based on record review and interview the facility failed to prevent misappropriation of resident's money for 1 (R #1) of 1 ( R#1) resident reviewed for exploitation when R #1 had $200 go missing from his jacket pocket after he observed Certified Nurse Aide (CNA) unzipping his jacket pocket. This deficient practice likely resulted in the resident feeling frustrated and having anxiety of his personal belongings not being safe in his room.

Inspectors wroteBased on record review, observation, and interview the facility failed to: 1) Post the staffing form in a prominent place that is readily accessible to residents and visitors for the facility's Posted Staffing List. 2) Update the list within 2 hours of the beginning of each shift to reflect the staff actually working and not just scheduled. These deficient practices could likely prevent the public as well as the 62 (1 - 62) residents identified on the facility census list provided by the Administrator on 02/19/23 to not have access to accurate, current and previous staffing information.

Inspectors wroteBased on record review and interview, the facility failed to have the necessary minimum committee members (Medical Director, Administrator, Director of Nursing, Infection Preventionist, and two other staff) for 1 of the 4 required Quality Assurance Performance Improvement (QAPI) meetings. This failure could likely affect all 62 (1 - 62) residents identified on the census presented by the Administrator on 02/19/22. By not having the required committee members at the quarterly QAPI meetings, issues may not be discovered or may be delayed in the care and improvements for the residents.