Artesia Healthcare & Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Artesia, New Mexico.
- Location
- 1402 West Gilchrist Ave, Artesia, New Mexico 88210
- CMS Provider Number
- 325128
- Inspections on file
- 23
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Artesia Healthcare & Rehabilitation Center, Llc during CMS and state inspections, most recent first.
The facility did not obtain required informed consent for multiple psychotropic and related medications given to several residents. One resident received melatonin for insomnia without a documented consent form. Another resident was given melatonin for insomnia and alprazolam for anxiety/restlessness with no corresponding consent forms in the record. A third resident received melatonin for insomnia, olanzapine for schizophrenia, and gabapentin for pain/bipolar disorder, again without any documented consents. In each case, the DON acknowledged that staff failed to complete the expected psychotropic medication consent forms before starting these medications.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment for multiple residents. Observations showed missing and broken electrical outlet covers near beds and an air conditioning unit, damaged drywall with large cracks, chipped paint, scuff marks, and a visible hole in a wall near a bed. In one room, trash was overflowing from the bin onto the floor. Handrails along several halls were scuffed, chipped, and had peeling paint. An LPN acknowledged the need for paint touch-ups on the handrails, and the DON stated that the facility should be safe, clean, neat, and orderly at all times.
Surveyors found that two residents were receiving melatonin, a psychotropic medication, ordered for insomnia without a corresponding insomnia diagnosis documented in their clinical records. Both residents had multiple medical and psychiatric conditions, and physician orders specified melatonin 5 mg for insomnia. In interview, the DON confirmed that the indication for each melatonin order was insomnia, acknowledged that neither resident had an insomnia diagnosis, and stated that medications are required to be documented as treating specific diagnosed conditions, which was not done in these cases.
Surveyors found that staff failed to develop accurate and complete baseline care plans for multiple newly admitted residents. One resident with significant medical conditions and observable dental issues had a baseline care plan that incorrectly stated she had her own teeth and omitted her upper denture and other dental problems. Another resident with complex psychiatric and infectious diagnoses, open wounds, constant pain, fall risk, and orders for antipsychotic medication had a baseline care plan that lacked instructions for wound care, pain management, fall prevention, infection management, and monitoring or use of antipsychotic therapy, despite confirmation by the ICN and DON of these needs.
Surveyors found that staff failed to revise care plans for multiple residents after significant changes in treatment and condition. For one resident with seizures, falls, and sleep apnea, the care plan did not include the use of a camera installed over the bed to monitor seizure activity, did not add interventions after several documented falls, listed an incorrect diet texture, and continued to show continuous O2 therapy even though the resident was no longer on continuous oxygen. For another resident with DM2 and mental health diagnoses, the care plan still directed staff to administer Insulin Glargine even though the insulin order had been discontinued in the medical record.
The facility did not update its daily nurse staffing posting at the beginning of the shift, resulting in outdated information being displayed. An observation found that the posted staffing data was from the previous day and did not reflect the current date, RN, LPN, and CNA staffing numbers and hours, or the current resident census. The MOD confirmed during interview that the staffing information had not been updated on a daily basis, affecting the availability of current staffing information for all residents.
Surveyors found that multiple residents were receiving medications without corresponding documented diagnoses or appropriate monitoring. Several residents were prescribed drugs such as ropinirole, allopurinol, Keppra, gabapentin, Suboxone, methocarbamol, benztropine, melatonin, risperidone, sertraline, and olanzapine for indications like RLS, gout, seizures, neuropathy pain, opioid use disorder, muscle stiffness/tremors, aggressive behaviors, agitation, and depression, even though these conditions were not consistently listed in their medical records or the indications were not clinically appropriate. In addition, residents on psychotropic medications, including antipsychotics and antidepressants, were not consistently monitored for side effects, behaviors, or sleep patterns as ordered or expected, despite ongoing administration of these medications. The DON confirmed these discrepancies between indications, diagnoses, and monitoring.
Surveyors found that kitchen staff did not consistently follow sanitary food preparation and storage practices, including a staff member working without required facial hair protection and multiple opened frozen food items (such as tater tots, meatballs, and French fries) stored in unlabeled and undated bags. The dietary supervisor confirmed expectations that all staff wear hairnets and beard nets in the kitchen or when serving food, and a dietary aide acknowledged that the freezer items should have been labeled and dated. These practices were identified as affecting all residents on the facility census and were described as likely to lead to foodborne illnesses if safe food handling and storage were not followed.
A resident was discharged, but the facility’s business office failed to ensure the resident was only financially liable for services actually rendered and did not issue a required refund within the mandated timeframe. The Business Office Manager confirmed that the facility received payment for a period after discharge that it should not have received and that the refund for the overpayment was delayed for several months before being mailed.
Two residents’ PASARR Level I screens were completed inaccurately, with one resident’s form incorrectly indicating a need for a Level II evaluation despite diagnoses including depression and mixed anxiety, and another resident’s form indicating no mental health issues despite documented schizophrenia, psychoactive substance abuse, and PTSD. In both cases, the DON acknowledged that Section E of the PASARR was completed incorrectly and did not accurately reflect the residents’ mental health conditions or screening needs.
A resident with identified fall risk had a care plan intervention to use a fall mat, but the mat was observed stored under the bed while the resident was lying in bed. An RN confirmed the mat should have been placed on the floor next to the bed, and the DON acknowledged that the recommended use was floor placement when the resident was in bed and that the care plan was not person-centered or specific about this recommendation.
A resident with an order for Losartan for hypertension had specific parameters requiring the medication to be held and the MD notified if the systolic BP was below 110, diastolic BP below 60, or pulse below 60. During a medication pass, an LPN recorded a BP of 103/61 and administered the Losartan despite the order to hold it under those conditions. In an interview, the DON confirmed that staff are expected to follow physician orders as written and that this did not meet expectations for medication administration.
A resident admitted with multiple complex conditions, including third-degree burns, bacteremia, and MDR pseudomonas, arrived with hospital discharge instructions for specific wound dressings to the right hand and both legs every 5–7 days and moisturizer application to the face, hand, and healed leg areas four times daily. The EHR contained no corresponding physician orders for wound care or moisturizer, and the baseline care plan, though noting multiple scabs and burns, lacked any wound care interventions. An ICN reported applying gauze to an open leg wound because it was sticking to the resident’s pants, and the DON confirmed that the resident’s hospital wound care instructions were not entered as orders or incorporated into the care plan.
A resident with multiple medical and psychiatric conditions, including a third-degree burn and opioid use disorder, had physician orders for Suboxone three times daily and PRN Oxycodone and Tylenol for pain, but Suboxone was not given for several days due to unavailability, and no PRN pain medications were administered or pain levels documented. The baseline care plan noted constant moderate pain but lacked any pain-related instructions or interventions. The resident later reported pain at the highest level on a 0–10 scale, and the DON confirmed that pain monitoring was not performed and that the care plan did not address pain management.
A resident was found using quarter-size bedrails for mobility and repositioning, with their use documented on a bedrail assessment, but no corresponding physician order was present in the medical record. During observation, bedrails were noted on both upper sides of the bed, and the resident confirmed using them to assist with mobility. In an interview, the DON acknowledged that the resident did not have a physician order for bedrails, even though such an order should have been obtained before installation.
A resident with hypertension had a physician’s order for Losartan 25 mg, 0.5 tablet daily, with instructions to hold the dose and notify the MD if BP or pulse fell below specific parameters. Review of the MAR and vital signs showed that staff administered the Losartan dose on multiple occasions even when the resident’s documented BP readings were below the ordered systolic or diastolic thresholds. In an interview, the DON acknowledged that the medication was given outside the prescribed parameters and identified this as a significant medication error, noting that nurses were expected to hold the medication and contact the physician when parameters were not met.
A resident receiving hospice services, with a history of Alzheimer's disease, dementia, epilepsy, and Down syndrome, was admitted to hospice with Down syndrome documented as the hospice diagnosis, which the DON stated did not meet her expectations as a qualifying hospice diagnosis. Review of the EHR showed that the hospice plan of care was not available in the record, and the DON confirmed the facility did not have a copy of the hospice plan of care while the resident was on hospice services.
A resident on enhanced barrier precautions (EBP) had a tube feeding performed by an LPN who wore gloves but did not don the required gown, despite EBP signage on the room door specifying gown and glove use for high-contact care. During interviews, the LPN initially stated a gown was not required for accessing the feeding tube, then later acknowledged after reviewing the sign that a gown should have been worn. The DON confirmed that tube feedings require appropriate PPE and that the observed practice did not meet expectations.
A facility did not submit the results of an internal abuse or neglect investigation to the State Survey Agency within the required five working days after an incident involving a resident. The Administrator confirmed the report had not been sent as required.
Staff failed to consistently document and monitor dishwasher temperatures, sanitizer concentrations, and food temperatures, with multiple days missing required logs. Observations showed the dishwashing machine operated below required standards and food was served at unsafe temperatures. The process for checking and logging sanitizer concentrations was not performed consistently, potentially affecting all residents receiving food from the kitchen.
The administrator did not report or thoroughly investigate an allegation of sexual assault between two residents after being informed by the Social Worker. The incident was not reported to the State Agency, and the administrator acknowledged the decision not to report during an interview.
A resident with significant cognitive impairment and inability to communicate was allegedly kissed by another resident, raising concerns of possible sexual abuse. Staff reported the incident internally, but the administrator, acting as Abuse Coordinator, decided not to report the allegation to the State Survey Agency, and no report was submitted as required.
A resident who was nonverbal and unable to defend herself was the subject of an alleged sexual assault by another resident. Staff reported the allegation, and the social worker notified the administrator, but both confirmed that a thorough investigation was not conducted. The incident was closed with a note that no signs of abuse were detected, without further substantiation.
The facility failed to provide a homelike environment for four residents, with issues such as peeling paint, unrepaired walls, worn handrails, and stained carpets. Staff, including the DOM and DON, confirmed the deficiencies, acknowledging that the environment did not meet expectations. A Corporate Representative noted awareness of the issues, expecting repairs to be handled both in-house and by outside vendors.
The facility failed to ensure accurate PASRR assessments for three residents, leading to potential misplacement and inadequate service provision. One resident with Down Syndrome and anxiety, another with cerebral palsy, and a third with multiple mental health diagnoses had incorrect PASRR documentation. The DON confirmed these inaccuracies during interviews.
A resident with a history of repeated falls and severe cognitive impairment did not receive the required post-fall neurological evaluations after multiple falls. The facility's protocol mandates a 72-hour evaluation period following each fall, but these evaluations were not completed. The Director of Nursing confirmed the failure to adhere to the protocol.
A resident with multiple diagnoses, including neuromuscular dysfunction of the bladder, had an indwelling foley catheter without documented orders specifying its necessity, type, or care. This oversight was confirmed by the DON and could increase the risk of infections.
A facility failed to maintain a medication error rate below 5%, resulting in a rate of 10.34%. An LPN administered blood pressure medications to a resident despite their vital signs not meeting the prescribed parameters, as the resident's blood pressure was 121/75, below the required 140/90. The medications included Amlodipine, Metoprolol Succinate, and Valsartan, which were to be held if the blood pressure was below 140/90. The DON confirmed the error, contributing to the facility's high medication error rate.
A resident received Metoprolol, Amlodipine Besylate, and Valsartan for hypertension outside the prescribed parameters, as the medications were administered despite the resident's blood pressure being below the threshold of 140/90. This significant medication error was confirmed by the DON, who stated that the medications were given on multiple occasions without following the physician's orders.
The facility's binding arbitration agreement failed to include a provision allowing residents or their representatives to rescind the agreement within 30 days of signing. This deficiency affected 20 residents who had signed the agreement, as confirmed by the Administrator during an interview.
The facility's binding arbitration agreement failed to include a provision for selecting a convenient venue for arbitration proceedings. This deficiency was confirmed by the Administrator and affected 20 residents who had signed the agreement, potentially deterring them from exercising their rights.
A nurse failed to clean the blood pressure cuff and vital sign equipment before and after taking vital signs for three residents, as observed during a survey. The nurse acknowledged the oversight, and the DON confirmed that cleaning should occur between each resident.
A facility failed to ensure a resident's advance directive was available in the EHR and in physical form. The resident had a DNR order, but the advance directive form was unsigned and not uploaded into the EHR. The DON confirmed the absence of a valid form, which could cause confusion and delay in life-saving procedures.
The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in documenting falls and the use of bed rails. One resident's MDS inaccurately reported no falls despite multiple incidents, while another's MDS failed to note the use of bed rails, contrary to observations and care plans. The DON confirmed these inaccuracies.
The facility failed to develop comprehensive care plans for two residents, omitting the use of grab bars despite their presence and necessity for mobility assistance. Both residents confirmed using the grab bars, and the DON acknowledged the lack of care plans addressing these assistive devices.
The facility failed to update care plans for two residents. One resident's care plan was not revised after discontinuation of an anticoagulant, and another resident's care plan lacked updates after a fall. The DON confirmed these oversights.
The facility failed to provide a clean and safe environment in the courtyard area, with issues such as bird feces, overgrown grass, scattered trash, and a hazardous garden hose. Both the Administrator and the DON confirmed the deficiencies, acknowledging that maintenance was responsible for the courtyard's upkeep.
The facility placed mothballs in the courtyard to deter cats, exposing residents to harmful chemicals. Multiple residents reported seeing and smelling the mothballs, with some experiencing irritation. The Administrator admitted to approving the use of mothballs without proper knowledge of their chemical content.
The facility failed to treat a resident with respect and dignity by not discussing plans for removing cats from the grounds before placing mothballs in the courtyard. The resident, who had an agreement to keep three cats, was distressed upon discovering the mothballs and was not informed beforehand.
Failure to Obtain Informed Consent for Psychotropic and Related Medications
Penalty
Summary
The facility failed to ensure residents and/or their representatives were informed in advance about medications and understood the reasons, risks, and benefits, as required for psychotropic medications. For one resident with an order for melatonin 9 mg at bedtime for insomnia, record review showed no consent form for the use of melatonin. During interview, the DON confirmed that staff did not obtain the required psychotropic medication consent form prior to the resident starting melatonin, despite the expectation that such forms be completed before initiating psychotropic medications. For a second resident with orders for melatonin 5 mg daily for insomnia and alprazolam 1 mg three times daily for anxiety/restlessness, record review revealed no consent forms for either medication, and the DON confirmed consents were not obtained prior to use. For a third resident with orders for melatonin at bedtime for insomnia, olanzapine in the morning and at bedtime for schizophrenia, and gabapentin three times daily for pain/bipolar disorder, there were no consent forms in the medical record for any of these medications. The DON verified that staff did not obtain the required psychotropic medication consent forms before these medications were started, contrary to facility expectations.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
Surveyors identified a failure by facility staff to maintain a safe, clean, comfortable, and homelike environment for multiple residents. During observations on various halls and in multiple resident rooms, surveyors found missing or broken electrical outlet covers in several rooms, including outlets near resident beds and an air conditioning unit. Additional observations revealed damaged drywall in several rooms, including a large crack extending from floor to ceiling, chipped paint, scuff marks around the bottoms of walls, closets, and near bathroom doors, and a visible hole in a wall near a bed. In one resident room, trash was observed overflowing from the trash bin onto the floor. Surveyors also observed that handrails throughout several halls were scuffed, chipped, and had missing paint in many places. During an interview, an LPN confirmed that the handrails needed to be touched up due to peeling and chipping paint. In a separate interview, the DON stated that the facility should be safe, clean, neat, and orderly at all times. These observations and interviews formed the basis of the deficiency related to the facility’s failure to maintain the building in a clean, safe, and comfortable manner for residents.
Psychotropic Medication Use Without Documented Insomnia Diagnosis
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications without documented medical necessity for two residents. For one resident with diagnoses including ESRD, adult failure to thrive, anxiety disorder, depression, and opioid dependence, record review showed a physician’s order dated 07/09/25 for melatonin 5 mg by mouth once daily for insomnia. During interview, the DON confirmed that the stated indication for the melatonin was insomnia, but the resident did not have an insomnia diagnosis in the clinical record. The DON further confirmed that medications should be documented to treat specific conditions as diagnosed, and this was not done for this resident. For a second resident with multiple diagnoses including schizophrenia, bipolar disorder, bacteremia, syphilis, MDR pseudomonas infection, third-degree burn of the left lower limb, cannabis use, stimulant use, and psychoactive substance use, record review showed a physician’s order dated 02/17/26 for melatonin 5 mg by mouth at bedtime for insomnia. In interview, the DON confirmed that the indication for melatonin was insomnia, but this resident also did not have an insomnia diagnosis documented in the record. The DON again acknowledged that medications should be documented to treat specific diagnosed conditions and that this requirement was not met, resulting in psychotropic medication use without corresponding documented diagnoses for both residents.
Failure to Develop Accurate and Complete Baseline Care Plans on Admission
Penalty
Summary
Surveyors identified a failure to create accurate baseline care plans containing the minimum health information necessary to properly care for newly admitted residents. For one resident with COPD, cirrhosis, critical illness myopathy, permanent atrial fibrillation, and nicotine dependence, observation showed she removed an upper denture and had missing, broken, or decayed lower teeth. However, her baseline care plan documented that she had her own teeth and did not indicate the presence of an upper denture or other dental issues. In an interview, the DON acknowledged that the resident’s upper denture and dental issues should have been included on the baseline care plan. For another resident admitted with schizophrenia, bipolar disorder, bacteremia, syphilis, MDR Pseudomonas, third-degree burn of the left lower limb, cannabis and stimulant use, and psychoactive substance use, the baseline care plan noted partial weight-bearing status with two-person assist and the presence of multiple scabs and burns. Despite this, the plan did not include instructions for wound or injury care, did not address the resident’s constant pain rated at 5, did not include interventions for identified fall risk, did not address the resident’s infection, and did not include information related to the use of ordered antipsychotic medication (Olanzapine 5 mg daily for schizophrenia). The ICN confirmed the resident was admitted with Morganii and CRAB, had an open wound, and was on transmission-based precautions, and the DON confirmed that the baseline care plan did not include the minimum healthcare information necessary to properly care for this resident.
Failure to Revise Care Plans After Changes in Treatment and Condition
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans for multiple residents after changes in condition, treatments, and interventions. For one resident with a history of seizures, falls, and sleep apnea, physician orders documented a regular pureed diet with thin liquids and oxygen at 2 L/min via nasal cannula with approval to wean off. Progress notes showed multiple falls on 11/14/25, 11/20/25, 12/04/25, and 02/04/26. Observation of the resident’s room revealed a camera positioned above the bed to monitor seizure activity and no oxygen concentrator present, and the resident was not wearing oxygen. However, the care plan last revised on 01/23/26 did not include any goals, instructions, or indications for the use of the camera, did not include interventions for the falls that occurred after 11/05/25, listed an incorrect diet texture of regular mechanical soft instead of puree, and continued to list oxygen therapy as continuous for sleep apnea. The DON confirmed that the camera use should be in the care plan but was not, that fall interventions had not been updated for the subsequent falls, that the diet texture in the care plan was incorrect, and that the care plan had not been revised to remove continuous oxygen. For another resident admitted with insomnia, depression, bipolar disorder, generalized anxiety disorder, and type 2 DM with unspecified complications, the physician record showed an order for Insulin Glargine 15 units subcutaneously daily that had been discontinued on 10/21/25. Despite this discontinuation, the resident’s care plan, last revised on 05/22/25, still contained an intervention to inject Insulin Glargine. This demonstrates that the care plan was not revised to reflect the discontinued insulin therapy. Across these residents, the survey findings show that the facility did not ensure care plans were updated to reflect current orders, treatments, and monitoring devices as required.
Failure to Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post required nurse staffing information daily at the beginning of each shift, as mandated. On 02/22/26 at 9:30 a.m., an observation showed that the staffing data posting displayed in the facility was dated 02/21/26, indicating it had not been updated for the current day. The posting therefore did not reflect the current date, nor the total number and actual hours worked by RNs, LPNs, and CNAs directly responsible for resident care per shift, along with the current resident census, for that day. During an interview at 9:40 a.m. on the same day, the Manager on Duty confirmed that the posted staffing information was for the previous day and acknowledged it had not been updated daily, affecting the availability of current staffing information for all 51 residents identified in the census.
Unnecessary Medications and Inadequate Psychotropic Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ drug regimens were free from unnecessary drugs by not aligning indications for use with current diagnoses and by not consistently monitoring psychotropic medications. For multiple residents, physician orders listed indications such as restless leg syndrome (RLS), gout, seizures, neuropathy pain, opioid use disorder, muscle stiffness/tremors, aggressive behaviors, agitation, and insomnia, but the corresponding diagnoses were not present in the medical record. The DON confirmed in interviews that medications should be documented to treat specific diagnosed conditions and that this was not done for these residents. One resident was prescribed ropinirole for RLS without having an RLS diagnosis. Another resident with diagnoses including DM2, depression, hyperlipidemia, insomnia, HTN, and CKD had orders for allopurinol for gout and Keppra for seizures, yet there were no diagnoses of gout or seizures in the record. A different resident with ESRD, adult failure to thrive, anxiety disorder, depression, and opioid dependence was ordered gabapentin for neuropathy pain without a neuropathy diagnosis, and torsemide with an indication of “diuretic therapy,” which the DON stated was not an appropriate indication of use. Additional residents were affected by similar issues. One resident with multiple psychiatric and infectious diagnoses, including schizophrenia, bipolar disorder, bacteremia, syphilis, and substance use, was ordered Suboxone for opioid use disorder, methocarbamol for “muscle relaxer,” and benztropine for stiffness/tremors, but did not have diagnoses of opioid use disorder or stiffness/tremors, and “muscle relaxer” was not considered an appropriate indication. Another resident with insomnia, depression, bipolar disorder, and generalized anxiety disorder was prescribed risperidone for aggressive behaviors without a diagnosis of aggressive behaviors. A resident with dementia with behavioral disturbance and major depressive disorder received melatonin for agitation and risperidone for unspecified dementia; the DON confirmed the resident did not have diagnoses of agitation or insomnia, and there was no order for monitoring risperidone side effects or tracking hours of sleep to justify continued melatonin use. For a resident with gangrene, frostbite with tissue necrosis, need for assistance with personal care, and schizophrenia, orders were in place for sertraline for depression and olanzapine for schizophrenia, along with orders for behavior monitoring due to antidepressant use and for antipsychotic side-effect monitoring. However, the MAR showed that while sertraline and olanzapine were administered, there was no documented monitoring for antidepressant side effects or psychotic behaviors during the review period. The DON confirmed that this resident did not have behavior monitoring for the antipsychotic and did not have side-effect monitoring for the antidepressant, and stated that this did not meet her expectations because psychotropic medications should be monitored for behaviors and side effects while residents are taking them. According to the report, this deficient practice could likely lead to adverse drug effects and poor patient outcomes.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
Surveyors identified a deficiency in food service sanitation when kitchen staff failed to follow required hair restraint and food labeling practices. During a kitchen observation, a dietary aide was seen working without a beard net, and the dietary assistant manager confirmed that this staff member was not properly wearing required facial hair protection, stating that her expectation was for all staff to wear hairnets and beard nets while in the kitchen or serving food. In the same observation period, surveyors noted multiple opened frozen food items, including what appeared to be tater tots, meatballs, and French fries, stored in bags that were not labeled or dated. The dietary aide confirmed that these freezer items were not labeled and dated and acknowledged that they should have been. These practices were determined to affect all 51 residents on the census and were described as likely to lead to foodborne illnesses if safe food handling and proper food storage were not followed. No specific resident medical histories or individual conditions were described in the report beyond the total number of residents potentially affected.
Failure to Timely Refund Overpayment After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a discharged resident was only held financially liable for services rendered and to provide timely refunds of overpayments. Record review of one resident’s electronic health record showed the resident was discharged on 10/22/25. During an interview on 02/26/26, the Business Office Manager confirmed that this resident was owed a refund for October and November 2025, that the facility received a payment in November that it should not have received, and that the facility did not issue the October refund within 30 days of discharge as required. The Business Office Manager further stated that the refund was not mailed until 02/20/26, approximately 120 days after the resident’s discharge, demonstrating that the resident was not refunded all monies due within the required timeframe.
Inaccurate PASARR Level I Screening for Mental Health Conditions
Penalty
Summary
The deficiency involves the facility’s failure to ensure PASARR Level I Identification Screens accurately reflected residents’ mental health diagnoses and need for Level II evaluations. For one resident with hemiplegia and hemiparesis following a stroke, Type II diabetes, depression, and mixed anxiety and depression, record review showed a PASARR form dated 06/20/25 that indicated a Level II PASARR was required. During interview, the DON stated that Section E of this PASARR should not have indicated the need for a Level II evaluation and acknowledged the form was not filled out correctly and did not meet her expectations because it was incorrect. For another resident admitted with schizophrenia, psychoactive substance abuse, and PTSD, review of the PASARR dated 12/29/25 showed that Section E indicated the resident had no mental health illness issues. In interview, the DON stated that the PASARR should have indicated the schizophrenia diagnosis in this section and confirmed that it did not, again stating this did not meet her expectations because it was incorrect. The survey findings note that 2 of 5 residents reviewed for PASARR accuracy had forms that did not correctly identify their diagnoses or need for secondary screening.
Failure to Implement and Clearly Specify Fall Mat Intervention in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of an accurate, comprehensive care plan for a resident with fall risk needs. The resident was admitted on a documented admission date, and the care plan, last revised on 03/31/25, included an intervention to offer a fall mat as indicated. During observation on 02/22/26 at 2:26 pm, the resident was seen lying in bed while the fall mat was stored underneath the bed rather than positioned for use. In a subsequent interview at 2:37 pm, an RN confirmed that the fall mat was not placed correctly and should have been on the floor next to the bed. Later, on 02/26/26 at 2:54 pm, the DON confirmed that the recommended use of the fall mat was for it to be placed on the floor next to the resident’s bed when the resident was in bed and further acknowledged that the care plan was not person-centered and did not specify the exact recommendations for fall mat use. This failure to both clearly specify and consistently implement the fall mat intervention in accordance with the resident’s care plan constituted the cited deficiency.
Failure to Follow Antihypertensive Medication Hold Parameters
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when staff did not follow a physician’s medication order for one resident. The resident had a physician’s order dated 10/24/25 for Losartan 25 mg, to give half a tablet by mouth once daily for hypertension, with instructions to notify the physician and hold the medication if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or pulse was less than 60. During a medication administration observation on 02/25/26 at 8:54 a.m., an LPN obtained a blood pressure reading of 103/61 and proceeded to administer the Losartan despite the order to hold the medication when systolic blood pressure was below 110. In a subsequent interview on 02/26/26 at 3:45 p.m., the DON stated that staff administering medications are expected to follow physician orders as written and that this situation did not meet her expectations for medication administration. This deficient practice was cited as a failure to provide quality care that meets professional standards for the resident when staff did not adhere to the prescribed parameters for administering antihypertensive medication.
Failure to Implement Hospital Discharge Wound Care Orders
Penalty
Summary
Staff failed to implement and follow hospital discharge orders for wound care and skin treatment for one resident. The resident was admitted with multiple complex diagnoses, including schizophrenia, bipolar disorder, bacteremia, syphilis, pseudomonas infection with multidrug resistance, third-degree burn of the left lower limb, and multiple psychoactive substance use disorders. Hospital discharge instructions dated 02/16/26 directed that dressings to the right hand and both legs be changed every 5–7 days with specific cleansing and application of Mepilex Ag secured with kerlix or tape, and that moisturizer be applied four times daily to the face, left hand, and healed areas on both legs. However, review of the resident’s electronic health record showed no physician orders entered for wound care or moisturizer. The baseline care plan dated 02/17/26 documented that the resident had multiple scabs and burns all over the body, but it did not include any instructions or interventions for care of these wounds and injuries. During an interview, the infection control nurse confirmed the resident had an open wound and stated she applied gauze to the right leg wound because it was sticking to the resident’s pants, indicating ad hoc care outside of formal orders. In a separate interview, the DON confirmed that the resident did not have wound care treatment orders or care plan interventions, acknowledged that the resident had arrived with wound care instructions, and stated that these instructions were not followed or implemented, which did not meet her expectations.
Failure to Administer Ordered Pain Medications and Monitor Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical and psychiatric diagnoses, including schizophrenia, bipolar disorder, bacteremia, syphilis, multidrug-resistant pseudomonas infection, and a third-degree burn of the left lower limb. Physician orders dated 02/17/26 included Suboxone 8-2 mg sublingual film three times daily for opioid use disorder, Oxycodone 15 mg by mouth every four hours as needed for moderate pain, and Tylenol 325 mg, two tablets by mouth every six hours as needed for pain or fever. The Medication Administration Record for February 2026 showed that Suboxone was not administered for four days (02/17/26 through 02/20/26) because the medication was not available in the facility, and there was no administration of either Oxycodone or Tylenol during this period. There was also no documentation of any pain level on the MAR. The resident’s baseline care plan dated 02/17/26 documented that the resident’s pain was constant with a pain level of five, but the care plan did not include any instructions or indications related to pain management. During an interview, the resident reported that his pain was usually at a level ten on a 0–10 pain scale. In a subsequent interview, the DON confirmed that the resident did not receive Suboxone as ordered due to unavailability, did not receive Oxycodone or Tylenol during the days Suboxone was unavailable, and that the resident’s pain level was not monitored during those days because pain monitoring had not been done for this resident. The DON further confirmed that the resident did not have pain monitoring in place and did not have a care plan that included instructions and interventions for pain management, despite the need for such measures.
Failure to Obtain Physician Order Prior to Bed Rail Installation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to obtain appropriate physician orders prior to installing and using bed rails for one resident. The resident was admitted on a documented admission date, and record review showed that the resident’s bedrail assessment, completed on a specified date, indicated the resident uses bedrails to enhance mobility. However, review of the resident’s physician orders revealed no order for the use of bedrails. During observation of the resident’s room, quarter-size bedrails were seen on the upper right and left sides of the bed, and in an interview the resident confirmed using the bedrails for mobility and repositioning. In a subsequent interview, the DON confirmed that the resident did not have physician orders for the use of bedrails and acknowledged that such orders should be in place prior to installation. This sequence of events—installation and use of bedrails documented in the assessment and observed in the room, resident-reported use of the rails, and the absence of corresponding physician orders—constituted the cited deficiency for one of two residents reviewed for bedrails.
Failure to Follow Antihypertensive Hold Parameters Resulting in Significant Med Error
Penalty
Summary
Surveyors identified a deficiency related to medication administration when nursing staff failed to follow a physician’s order for an antihypertensive medication for one resident. The physician’s order, dated 10/24/25, directed that Losartan 25 mg, 0.5 tablet by mouth once daily for hypertension, be held and the MD notified if the resident’s systolic BP was less than 110, diastolic BP less than 60, or pulse less than 60. Review of the February 2026 MAR showed that staff administered 0.5 tablet of Losartan on 02/02/26, 02/07/26, 02/15/26, 02/21/26, and 02/25/26 despite documented blood pressures that were outside the ordered parameters on those dates, including readings of 108/60, 108/72, 100/65, 107/72, and 103/61, respectively. During interview, the DON confirmed that the resident received blood pressure medication outside the prescribed parameters and characterized this as a significant medication error, stating that nurses were expected to follow the order, hold the medication, and call the physician when parameters were not met.
Failure to Maintain Appropriate Hospice Diagnosis and Plan of Care Documentation
Penalty
Summary
Surveyors identified that the facility failed to ensure hospice services met professional standards for one resident receiving hospice care. The resident had a medical history that included Alzheimer's disease, dementia, epilepsy, and Down syndrome, and was originally admitted to the facility on one date and re-admitted on another. Record review of the hospice admission order form showed the resident was admitted to hospice with a diagnosis of Down syndrome listed as the hospice diagnosis. During interview, the DON confirmed that this diagnosis did not meet her expectations as a qualifying diagnosis for hospice care. Further review of the resident's EHR revealed that the hospice plan of care was not available in the facility's records, and the DON confirmed the facility did not have a record of the resident's hospice plan of care. These findings show that the facility did not ensure the resident had an appropriate qualifying hospice diagnosis documented and did not maintain the hospice plan of care in the resident’s record while the resident was receiving hospice services.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not following enhanced barrier precautions (EBP) for a resident on EBP. On 02/22/26, a sign posted on the door of Resident #10’s room indicated that the resident was on EBP, requiring targeted gown and glove use during high-contact resident care activities. On 02/24/26 at 1:27 pm, during observation of Resident #10’s tube feeding, LPN #1 accessed the resident’s feeding tube while wearing gloves but did not don the required gown as specified by the EBP signage. During an interview at that time, LPN #1 stated he was not required to wear a gown when accessing the feeding tube. In a second interview at 1:35 pm the same day, LPN #1 stated he had reviewed the EBP sign on the door and realized he should have been wearing a gown. On 02/26/26 at 3:45 pm, the DON stated that tube feedings require proper personal protective equipment and that the observed practice did not meet her expectations. The report notes that this failure to utilize EBP when performing personal care for Resident #10, one of two residents reviewed for EBP, has the potential to spread organisms, diseases, and other health conditions among residents.
Failure to Timely Report Investigation Results to State Survey Agency
Penalty
Summary
The facility failed to submit the results of an abuse or neglect investigation to the State Survey Agency within five working days as required. Record review showed that an incident involving one resident occurred on 11/13/25 and the facility completed its internal investigation. However, there was no evidence that the results of this investigation were reported to the State Survey Agency within the mandated timeframe. During an interview, the Administrator confirmed the facility's responsibility to submit the five-day follow-up report and was unable to verify that the required report for this incident had been sent.
Failure to Document and Monitor Food Safety and Sanitation Procedures
Penalty
Summary
The facility failed to consistently document and monitor critical food safety and sanitation procedures in the kitchen, as required by both facility policy and manufacturer guidelines. Specifically, staff did not complete daily sign-off sheets or record dishwasher temperatures and sanitizing solution concentrations, with multiple days missing documentation. Observations revealed that the dishwashing machine was operated below the minimum required temperatures and with inadequate sanitizer concentration, as measured by test strips, on several occasions. The assistant dietary manager and administrator confirmed that these logs were not being completed as required and that the dishwashing process was not meeting proper sanitization standards. Additionally, the facility did not consistently document food temperatures for meals, with numerous instances where breakfast, lunch, or dinner temperatures were not recorded. During an observation, food intended for resident delivery was found to be inadequately covered and at a temperature significantly below safe serving standards. The administrator acknowledged that the method of food transfer and temperature maintenance was not appropriate, and that food temperatures were not being logged as required for each meal. The facility also failed to document daily testing of kitchen sanitizing solutions, with several days missing from the sanitizer test strip log. The assistant dietary manager confirmed that the process of checking and logging sanitizer concentrations was not performed consistently, which is necessary to ensure that cleaning solutions are effective in killing bacteria. These failures in documentation and monitoring could potentially affect all residents who consume food prepared in the facility's kitchen.
Failure to Report and Investigate Alleged Sexual Assault
Penalty
Summary
The facility administrator failed to report and thoroughly investigate an allegation of sexual assault involving two residents. According to a grievance report, staff reported a possible sexual assault to the Social Worker, who then informed the Administrator on the same day. However, the Administrator did not report the allegation to the State Agency, as confirmed during an interview, citing concerns about the facility's record. A review of the New Mexico Health Care Authority complaints intake confirmed that no report of the incident had been received from the facility. This lack of reporting and investigation constitutes a deficiency in the facility's administration and handling of abuse allegations.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of possible sexual abuse involving a resident with significant cognitive impairment, as indicated by a BIMS score of zero, who was unable to communicate verbally or defend herself. Staff reported concerns after another resident was seen kissing the vulnerable resident, and the housekeeper relayed these concerns to the social worker. The social worker received the grievance and reported it to the administrator, who also serves as the Abuse Coordinator. Despite the allegation and the resident's inability to communicate or defend herself, the administrator determined that sexual abuse had not occurred and did not report the incident to the State Survey Agency. Record review confirmed that the required report was not submitted to the State Agency.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who was unable to communicate verbally or defend herself. According to the grievance report, staff reported a possible sexual assault involving two residents, with the alleged perpetrator denying the incident and the alleged victim unable to provide verbal input. The social worker confirmed receiving the grievance and reporting it to the administrator. However, both the social worker and the administrator acknowledged that a comprehensive investigation was not completed, and the final outcome was documented as no sign of abuse detected without further substantiation.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for four residents, as evidenced by several environmental deficiencies. Observations revealed issues such as peeling and chipped paint, unrepaired wall damage, worn and damaged handrails, stained and faded carpets, and incomplete wall repairs. These deficiencies were noted in various areas of the facility, including the 200 and 300 halls, the main entrance, and near the nurses' station. Specific resident rooms also exhibited issues such as chipped paint and exposed, crumbling sheetrock. Interviews with facility staff, including the Director of Maintenance, Director of Nursing, and a Corporate Representative, confirmed awareness of these issues. The Director of Maintenance acknowledged that the current state of the environment does not constitute a homelike setting. The Director of Nursing expressed that the environment did not meet her expectations for a homelike atmosphere. The Corporate Representative stated that they were aware of the issues and expected smaller repairs to be completed in-house, while larger repairs would be handled by an outside vendor. However, these expectations had not yet been met, resulting in the noted deficiencies.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, leading to potential misplacement and inadequate service provision. Resident #9 was admitted with diagnoses including Down Syndrome and anxiety, yet the PASRR inaccurately documented no evidence of intellectual or developmental disability and no suspected mental illness. The Director of Nursing (DON) confirmed the inaccuracies in the PASRR documentation during an interview. Similarly, Resident #30, who was admitted with cerebral palsy and a history of mental and behavioral disorders, had a PASRR that incorrectly indicated no evidence of intellectual or developmental disability. The DON acknowledged the error, noting that cerebral palsy is specifically listed in the PASRR criteria. Additionally, Resident #45, with multiple mental health diagnoses including bipolar disorder and anxiety, had a PASRR that failed to recognize any suspected mental illness. The DON admitted that the facility did not ensure the PASRR was correct prior to admission.
Failure to Complete Post-Fall Neurological Evaluations
Penalty
Summary
The facility failed to prevent an accident for a resident who was reviewed for falls. The staff did not complete post-fall neurological evaluations for the resident, who had a history of repeated falls and severe cognitive impairment. The resident was admitted with diagnoses including anxiety, Down Syndrome, neuromuscular dysfunction of the bladder, and a need for assistance with personal care. Despite the resident's condition and history of falls, the facility did not adhere to its protocol for conducting neurological evaluations after each fall. The facility's Neurological Evaluation Flow Sheet outlined a specific schedule for post-fall evaluations, requiring assessments every 15 minutes for the first two hours, every 30 minutes for the next two hours, every hour for four hours, and every eight hours for an additional 64 hours, totaling a 72-hour evaluation period. However, the facility failed to complete these evaluations for the resident after falls on multiple occasions. The Director of Nursing confirmed that the required neurological evaluations were not completed as per the facility's protocol, which mandates such evaluations for every unwitnessed fall for at least 72 hours.
Lack of Catheter Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident with a foley catheter had a documented order demonstrating the necessity of the catheter, specifying the type of catheter needed, and detailing the required care for the catheter. This deficiency was identified for one of the two residents reviewed for catheter use. The absence of such documentation could likely result in an increased and unnecessary risk of infections for the residents. The resident in question was admitted with multiple diagnoses, including anxiety, Down Syndrome, neuromuscular dysfunction of the bladder, repeated falls, and a need for assistance with personal care. Despite the presence of an indwelling foley catheter, as observed during a survey, the resident's medical records lacked any current orders for the catheter's use, type, or care. The Director of Nursing confirmed the absence of these orders, acknowledging that the facility should have them documented.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 10.34% during a medication administration review. This deficiency was identified when an LPN administered blood pressure medications to a resident despite the resident's vital signs not meeting the prescribed parameters. Specifically, the resident's blood pressure was recorded at 121/75, and the pulse was 78 beats per minute, which were below the threshold of 140/90 as specified in the physician's orders. The medications administered included Amlodipine, Metoprolol Succinate, and Valsartan, all of which were to be held if the blood pressure was below 140/90. The Director of Nursing confirmed that the LPN made a medication error by administering the medications outside the prescribed parameters. This error was part of three medication errors observed out of 29 opportunities during the survey, contributing to the facility's medication error rate exceeding the acceptable limit. The failure to adhere to the physician's orders for medication administration could potentially lead to residents not receiving the desired therapeutic effect and being exposed to a higher risk of side effects.
Significant Medication Error Due to Non-Adherence to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's orders for medication administration. The resident was prescribed Metoprolol, Amlodipine Besylate, and Valsartan for hypertension, with specific instructions to hold the medication if the blood pressure was below 140/90 and to notify the provider if the pulse was below 60. However, the staff administered these medications on multiple occasions despite the resident's blood pressure being below the prescribed threshold. The Medication Administration Record (MAR) for February and March 2025 showed that the medications were given on fourteen different occasions when the resident's blood pressure was under 140/90. This action was confirmed during an interview with the Director of Nursing, who acknowledged that the medications were administered outside the prescribed parameters, constituting a significant medication error. The failure to follow the physician's orders could potentially lead to adverse side effects or a lack of therapeutic effect for the resident.
Arbitration Agreement Lacks Rescission Clause
Penalty
Summary
The facility failed to ensure that their binding arbitration agreement explicitly granted residents and/or their representatives the right to rescind the agreement within 30 calendar days of signing. This deficiency was identified for 20 out of 49 residents who had signed the arbitration agreement. The facility's arbitration agreement did not include a provision for the ability to rescind the agreement, which was confirmed during an interview with the Administrator. The Administrator provided a list of the 20 residents affected by this deficiency. A record review of the facility's arbitration agreement revealed that it was undated and lacked the necessary provision for rescission within 30 days. This oversight was acknowledged by the Administrator during an interview, confirming that the agreement did not address the residents' right to rescind.
Lack of Venue Provision in Arbitration Agreement
Penalty
Summary
The facility failed to ensure that their binding arbitration agreement included a provision for the selection of a convenient venue for arbitration proceedings. This omission could potentially lead to frustration and difficulty for residents who wish to seek arbitration, as they may be deterred from exercising their rights. The deficiency was identified during a record review of the facility's undated binding arbitration agreement, which lacked the necessary provision for venue selection. The issue was confirmed during an interview with the Administrator, who acknowledged that the agreement did not contain a provision for a convenient venue selection. This affected 20 out of 49 residents who had signed the agreement, as identified by the list provided by the Administrator.
Failure to Clean Vital Sign Equipment Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention practices when a nurse did not clean the blood pressure cuff and vital sign equipment before and after taking vital signs for three residents. During an observation, Nurse #1 was seen taking vital signs for Resident #22, Resident #28, and Resident #152 without cleaning the equipment between uses. In an interview, Nurse #1 acknowledged the oversight and stated that he should have cleaned the equipment before and after each resident. The Director of Nursing also confirmed that she expected all nurses to adhere to this practice.
Failure to Ensure Availability of Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was available in both the Electronic Health Record (EHR) and in physical form for staff access. The resident, identified as having a Do Not Resuscitate (DNR) order, did not have a valid advance directive form in their EHR. The New Mexico medical orders for scope of treatment (MOST) require the form to be signed by both an authorized healthcare provider and the patient or decision maker to be valid, but the form was unsigned. During an interview, the Director of Nursing (DON) confirmed that the advance directive was not signed by the physician and was not uploaded into the EHR, nor was there a valid written form available for nursing staff. This oversight could lead to confusion and delay in potentially life-saving procedures.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, which could result in their preferences and care needs not being met. For one resident, the MDS assessment inaccurately reported that the resident had not experienced any falls since admission, despite multiple documented falls and a care plan indicating a risk for falls. The Director of Nursing (DON) confirmed the inaccuracy and acknowledged that the MDS should reflect the resident's fall history. For another resident, the MDS assessment inaccurately indicated that bed rails were not in use, despite observations and care plan documentation showing that the resident's bed had rails on both sides to assist with mobility and positioning. The DON confirmed this discrepancy, stating that the MDS should accurately reflect the resident's use of bed rails. These inaccuracies in the MDS assessments highlight a failure in accurately documenting and assessing the residents' conditions and care needs.
Deficient Care Planning for Assistive Devices
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered comprehensive care plan for two residents, which could result in staff being unaware of the residents' current and actual needs. Resident #3 was admitted with multiple diagnoses, including pain in the right hip and knee, history of falling, muscle weakness, difficulty walking, and lack of coordination. Despite the presence of grab bars on each side of Resident #3's bed, the care plan dated 12/18/24 did not include the use of these grab bars. During an interview, Resident #3 confirmed using the grab bars for repositioning and bed mobility, and the Director of Nursing acknowledged the absence of a care plan for the grab bars. Similarly, Resident #45, who was admitted with diagnoses such as legal blindness, difficulty walking, lack of coordination, and abnormalities of gait and mobility, also had a grab bar on the upper left side of the bed. However, the care plan dated 01/28/25 did not address the use of the grab bar. Resident #45 confirmed using the grab bar to assist with getting up from the bed, and the Director of Nursing admitted that there should have been a care plan for the grab bar. These omissions in care planning could lead to staff being unaware of the residents' needs for assistive devices.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, which could result in their care and needs not being adequately addressed. For the first resident, the care plan indicated a risk for abnormal bleeding due to the use of the anticoagulant Plavix. However, the medication was discontinued in January 2025, and the care plan was not updated to reflect this change. The Director of Nursing confirmed that the care plan should have been revised to reflect the discontinuation of the anticoagulant. For the second resident, the care plan addressed the risk for falls due to several medical conditions and previous falls. Despite sustaining a fall in February 2025, the care plan was not updated with new interventions to address this incident. The Director of Nursing acknowledged that the care plan should have been revised to include interventions for the recent fall.
Failure to Maintain a Safe and Clean Courtyard
Penalty
Summary
The facility failed to provide a clean and safe environment for its residents, as observed in the courtyard area. During a random observation, surveyors noted several issues: a black office chair with bird feces on it, a sidewalk 75 percent covered with bird feces, pecans, and pecan shells, making it impassable for residents. Additionally, the trash can lid could not be closed due to being overfilled with empty cigarette boxes, the grass was 8 to 10 inches tall in some areas, and various items such as used napkins, a coffee cup, cigarette box wrappers, and used tissues were scattered throughout the courtyard. A garden hose stretched across the sidewalk posed a safety risk for residents walking in the area. These conditions were confirmed by both the Administrator and the Director of Nursing, who acknowledged that the courtyard did not provide a safe and clean environment and that maintenance was responsible for its upkeep. Further observations revealed that the courtyard's unsafe conditions persisted, as evidenced by a resident using a walker to navigate over a water hose stretched across the sidewalk. The Administrator and the Director of Nursing both confirmed the deficiencies, with the Director of Nursing mentioning that she had previously had to mow the lawn herself. These findings indicate a failure to maintain a safe and clean environment, which is essential for the residents' well-being and ability to enjoy outdoor activities.
Improper Use of Mothballs in Courtyard
Penalty
Summary
The facility failed to keep all 44 residents free from potential accidents or hazards by placing mothballs in the courtyard area. The Material Safety Data Sheet (MSDS) for naphthalene, the main chemical in mothballs, indicated that short-term or long-term side effects could occur if inhaled or absorbed through the skin. Multiple residents reported seeing and smelling the mothballs, with some experiencing irritation in their eyes, mouth, and throat. One resident even picked up and disposed of some mothballs. A Certified Nursing Assistant (CNA) confirmed seeing the mothballs and assisted in their removal. The Administrator admitted to approving the use of mothballs without proper knowledge of their chemical content, and the Activities Assistant noted that there were well over 100 mothballs in the courtyard, which residents complained about due to the strong odor. Interviews with residents and staff revealed that the mothballs were placed in the courtyard to keep cats away from the facility. However, this action led to several residents being exposed to the chemicals, causing discomfort and potential health risks. The Administrator's lack of awareness regarding the hazards of mothballs and the subsequent placement of these chemicals in a common area where residents frequently go to smoke contributed to the deficiency. The facility's failure to recognize and mitigate this hazard compromised the safety and well-being of its residents.
Failure to Respect Resident's Agreement and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not discussing plans for removing cats from the facility grounds prior to placing mothballs in the courtyard area. The resident, who had an agreement with the previous administrator and the Ombudsman to keep three cats, discovered the mothballs and was distressed, fearing for her cats' safety. The current administrator confirmed the existence of the agreement but admitted there was no documentation and that the resident was not notified before the mothballs were placed.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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