Belen Meadows Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Belen, New Mexico.
- Location
- 1831 Camino Del Llano, Belen, New Mexico 87002
- CMS Provider Number
- 325068
- Inspections on file
- 28
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Belen Meadows Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and major depression had an unwitnessed fall in her room that resulted in a swollen hand. Staff performed an assessment, notified a provider via Telehealth, and obtained an x-ray to rule out injury, which showed no fracture or dislocation. Despite the facility’s abuse prohibition policy requiring immediate reporting of alleged injuries and injuries of unknown source to the State Agency, the DON and ADM acknowledged that this unwitnessed fall with potential injury met reporting criteria but was not reported.
The facility did not replace the ice machine filters by the recommended date, as observed on two occasions. Both the District Manager and Maintenance Director confirmed the filters were overdue for replacement and acknowledged responsibility for this task.
The facility did not ensure proper infection control practices when laundry staff repeatedly found used shaving razors in dirty towels, with incidents not reported to the Infection Control Preventionist or DON. Additionally, the Water Management Program lacked procedures, control limits, monitoring protocols, and interventions to minimize Legionella risk, and facility leadership was unaware of these deficiencies.
A resident with a chronic sacral pressure ulcer repeatedly refused wound care during the night shift, expressing a preference for daytime care. Despite these requests, staff continued to attempt wound care at night, and there was no documentation of any change to the care plan or physician orders to accommodate the resident's wishes. Nursing notes and interviews confirmed the resident's refusals and preferences, but the facility did not adjust care practices or document reasons for missed wound care.
Staff did not maintain a safe and homelike environment, as evidenced by burnt-out lights, damaged walls, and missing blinds in the dining area, as well as broken fixtures, water leaks, foul odors, and pest infestations in several resident rooms and bathrooms. Residents reported ongoing maintenance issues and discomfort, while maintenance staff acknowledged responsibility but did not complete necessary repairs.
Surveyors found that staff administered medications with an error rate of 8.6%, exceeding the 5% threshold. Errors included a resident receiving levothyroxine and apixaban outside of prescribed timeframes, and another resident being given Artificial Tears without an active provider order. CMAs cited workload and misunderstanding of order status as contributing factors, and the DON confirmed that medications should only be given as ordered and within specified timeframes.
A treatment cart containing wound care supplies and medical tools was left open and unattended by a nurse, making its contents accessible. The DON confirmed that all treatment carts are expected to be locked when not attended by staff.
A resident with diabetes, morbid obesity, and legal blindness was not provided with meals that matched her documented vegetarian diet preference, including no eggs or meat. Despite repeated reminders to staff, the resident continued to receive meals containing meat, such as pork sandwiches, and was left hungry. Facility records showed conflicting diet orders, and staff interviews confirmed the resident's dietary needs were not consistently met.
Two residents experienced deficiencies in medical record-keeping, including discrepancies in documentation of fall events and missing entries in ADL flow sheets. The Corporate Nurse and DON acknowledged issues with inaccurate records and incomplete documentation, with contributing factors including staff access to electronic records and short duration of stay.
A resident with a documented diagnosis of major depressive disorder and related symptoms was not accurately identified as having a mental illness on the PASARR Level I Identification Screening. The facility's records and staff interview confirmed that the screening failed to reflect the resident's mental health diagnosis, contrary to policy and assessment findings.
A resident with dementia and a history of left femur fracture experienced a fall resulting in increased pain and visible distress. Despite escalating pain levels and abnormal physical findings, there was a significant delay in obtaining x-rays and transferring the resident to the hospital. Staff interviews revealed lapses in communication and timely intervention, leading to prolonged pain before the resident received appropriate care.
A resident with multiple health conditions was found sleeping on a deflated alternating air mattress, despite provider orders and care plans specifying its use. Staff interviews confirmed that nursing staff were responsible for checking such equipment, but the mattress was not properly inflated at the time of observation.
Staff did not date the oxygen humidifier bottle for a resident with CHF and anemia, despite facility policy and provider orders requiring dating and weekly replacement of oxygen equipment. The undated humidifier was observed in use, and both a nurse and the DON acknowledged the requirement for proper labeling and replacement.
Staff did not dispose of a completed medication after a resident's treatment ended, leaving an opened bottle of artificial tears in the medication cart and failing to document its removal as required by facility policy. The nurse responsible for medication destruction did not receive the medication, and the DON confirmed that completed medications should not remain in carts.
A resident did not receive required annual dental care, with the last documented dental visit occurring nearly two years prior. Although there was an order for a dental appointment, there was no evidence the appointment occurred, and the order was discontinued. The facility relied primarily on the driver to track and schedule dental appointments, while other staff were unaware of the missed care. The DON stated that the responsibility should have been shared by the IDT.
A resident with a history of falls and limited mobility was observed using a wheelchair with a detached back bar, which had been broken for an extended period. An LPN noticed the issue and verbally reported it but did not document it, and the PT confirmed the wheelchair was unsafe and missing necessary parts. The resident continued to use the unsafe wheelchair until the issue was addressed.
The facility failed to provide written notification to residents and their representatives about room changes due to a flooding event. Although families were informed by phone, there was no written documentation provided, affecting eight residents. The Director of Nursing confirmed the lack of written notifications, which is required for room changes.
The facility failed to document medication refrigerator temperatures, as required, for several days. This was discovered through record review and observation, revealing that insulin and other medications requiring refrigeration were stored without proper temperature monitoring. The DON confirmed that staff must check and document temperatures twice daily to ensure they remain within the necessary range.
The facility failed to serve meals according to dietary meal tickets for three residents. One resident did not receive double portions as required, another had multiple missing items and incorrect meals, and a third reported frequent mismatches between the menu and served food. The Regional Dietary Manager confirmed these issues.
A resident's bathroom doorknob was broken for several weeks, preventing access to the restroom. Despite a work order being submitted, the repair was not completed, and the facility's administrator was unaware of the status. The resident, who was continent and able to toilet independently, had informed CNAs about the issue.
The facility failed to maintain an accurate care plan for a resident, including conflicting statements about smoking status. The care plan initially prohibited smoking, then allowed supervised smoking, despite the resident having no history of smoking. The DON confirmed the inaccuracies during an interview.
A facility failed to revise a resident's care plan accurately, which continued to indicate an active UTI despite the resident not having one since February. The care plan, dated June, should have reflected the resident's risk for developing UTIs. The DON confirmed the oversight during an interview.
The facility failed to obtain wound care orders for a resident with pressure sores, leading to confusion and lack of documented care. Despite the wound care nurse documenting the sacral wound and an order being placed, the treatment administration record did not reflect this, causing inconsistencies in wound care management.
Failure to Report Unwitnessed Fall With Potential Injury to State Agency
Penalty
Summary
The facility failed to report an alleged incident involving an unwitnessed fall with potential injury to the State Agency as required by its Abuse Prohibition policy. The policy, revised on 11/14/25, prohibits neglect and requires immediate reporting, investigation, documentation, and follow-up of alleged injuries, including injuries of unknown source. It directs the facility to initiate an investigation within 24 hours of receiving information about an injury or suspected neglect, document interviews and findings, notify the physician and resident representative, and submit findings of completed investigations within five days to the State Agency. Record review showed that a resident with dementia, muscle weakness, and major depression experienced an unwitnessed fall in her room, after which staff documented a swollen left hand. A Telehealth provider was contacted and ordered an x-ray of the hand, which later showed no fracture or dislocation. The DON stated that an unwitnessed fall with hand swelling and an x-ray to rule out injury met the criteria for reporting to the State Agency due to the potential for injury. The Administrator confirmed awareness of the fall and acknowledged that the incident should have been reported to the State Agency but was not, resulting in the failure to follow the facility’s abuse/neglect reporting requirements.
Failure to Replace Ice Machine Filters Timely
Penalty
Summary
The facility failed to ensure timely replacement of the filters on the ice machine, as observed on two separate occasions. The filters displayed a replacement date of 04/24/25, and instructions on the filters indicated they should be changed at least once per year. Despite this, the filters had not been replaced by the time of the second observation. During interviews, the District Manager confirmed that the Maintenance Director was responsible for changing and ordering the filters, and the Maintenance Director acknowledged that the filters needed to be changed.
Deficient Infection Control in Laundry Handling and Legionella Water Management
Penalty
Summary
The facility failed to follow proper infection control practices in two key areas: handling of laundry contaminated with used sharps and implementation of an adequate Water Management Program (WMP) to minimize the risk of Legionella. Observations revealed that laundry staff found used shaving razors in dirty towels brought to the laundry room, and these razors were subsequently placed in sharps disposal containers. The laundry technician reported finding razors in the laundry but could not recall when or to whom the incidents were reported. Both the Infection Control Preventionist and the Director of Nursing were unaware of these incidents, indicating a lack of communication and reporting regarding the presence of sharps in laundry. Facility policy on needle handling and sharps injury prevention did not address the risk of sharps contaminating linen or provide guidance on preventing such occurrences. Additionally, the facility's WMP was found to be inadequate in several areas. The policy lacked procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system, did not specify control limits or parameters, and failed to include monitoring procedures or environmental testing protocols for Legionella. There were also no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case. During interviews, facility leadership acknowledged that the WMP was reviewed annually but were unaware of its deficiencies in addressing Legionella risk.
Failure to Honor Resident's Preference for Wound Care Timing
Penalty
Summary
The facility failed to honor a resident's preference regarding the timing of wound care. The resident, who had quadriplegia, chronic pain, anxiety, depression, and a chronic sacral pressure ulcer, had physician orders for wound care to be performed twice daily on both day and night shifts. Documentation showed that wound care was frequently attempted during the night shift, but the resident repeatedly refused, stating a preference for wound care to be done during the day. Despite these refusals and the resident's clear requests, staff continued to attempt wound care at night, and there was no documentation of any adjustment to the care plan or physician orders to accommodate the resident's wishes. Nursing progress notes indicated multiple instances where the resident refused wound care at night and requested it be performed during the day. Interviews with the DON and Unit Manager confirmed awareness of the resident's refusals and preferences, but there was no evidence in the medical record, care plan, or orders that the timing of wound care was discussed or changed in response. Additionally, there was a lack of documentation explaining missed wound care opportunities or refusals on certain days.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Staff failed to maintain a safe, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies in the dining room and resident rooms. Observations revealed that the dining room had several burnt-out fluorescent and chandelier bulbs, scuffed walls with missing paint, and window blinds with missing slats. The Maintenance Director acknowledged responsibility for these areas and confirmed that the lights, walls, and blinds should have been maintained in good condition. In resident rooms and bathrooms, issues included non-functional hot water faucets, broken and uneven floor tiles, slow-draining sinks, standing water, foul odors, cracked windows, broken bed footboards, and partially detached window screens. Residents reported water leaks during rain, persistent foul odors, and unaddressed maintenance requests. The Maintenance Director was aware of some issues but stated repairs were not completed. Additionally, one resident's bathroom was repeatedly observed to have a significant presence of flies over several days, with the resident confirming the ongoing issue and expressing discomfort. Certified Nurse Aide (CNA) staff stated they would report hazards but were unaware of the specific problems observed, including the presence of flies. The Maintenance Director was not aware of the fly infestation and agreed the issue should have been addressed. These failures affected both common areas and multiple resident rooms, impacting the environment and comfort of the residents.
Medication Error Rate Exceeds 5% Due to Timing and Order Lapses
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in an observed error rate of 8.6% during the survey. For one resident with a history of venous thrombosis, embolism, and hypothyroidism, a Certified Medication Aide (CMA) administered levothyroxine and apixaban outside of the prescribed timeframes. Levothyroxine was not given 30 to 60 minutes before breakfast as ordered, and apixaban was not administered within the specified two-hour window. The CMA attributed the late administration to being assigned to two resident halls, which delayed medication delivery. The resident had already eaten breakfast before receiving the morning medications, contrary to the provider's orders and facility policy. In another instance, a different CMA administered Artificial Tears to a resident who exhibited redness and irritation around the eyes. However, the order for Artificial Tears had expired, and the medication was given without an active provider order. The CMA believed there was an active order but acknowledged that all medications require a current order before administration. The Director of Nursing confirmed that medications should not be administered without an active order and that it is the responsibility of both the CMAs and nurses to ensure orders are up to date before giving any medication.
Unattended and Unlocked Treatment Cart Exposes Medical Supplies
Penalty
Summary
Staff failed to secure a treatment cart on the 200 Unit, leaving the top drawer open and unattended while staff were away from the area. Observations revealed that the cart contained wound care dressings, wound cleanser, tweezers, barrier cream, irrigation solution, and scissors, all of which were accessible due to the unlocked and open drawer. During interviews, a registered nurse acknowledged responsibility for the unlocked cart, stating he had stepped away to assist a resident and left the cart open. The Director of Nursing confirmed that staff are expected to lock all treatment and medication carts when not in attendance and reiterated that carts should never be left open and unattended.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
A deficiency occurred when a resident with a documented vegetarian diet preference, including no eggs and no meat, was not provided with meals that honored these preferences. The resident's admission diet order specified a regular vegetarian diet with no eggs or meat, but the care plan did not address these dietary restrictions. The Minimum Data Set (MDS) listed a diabetic diet, and the resident's lunch ticket indicated a regular diet, resulting in the resident being served meals containing meat, such as a pork sandwich. The resident reported consistently receiving meat with meals and only being able to eat the salad, leading to hunger and repeated reminders to staff about her dietary needs. Interviews with facility staff revealed confusion regarding the resident's diet orders, with multiple conflicting diet orders present in the system, including regular, consistent carbohydrate (CCHO), and vegetarian diets. The Dietary Director acknowledged the lunch ticket was incorrect and confirmed the resident should have been on a CCHO and vegetarian diet. The DON was unaware the resident had received the incorrect diet and stated the expectation was for all residents to receive the correct diet. The failure to provide the appropriate diet was confirmed through record review, observation, and interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with dementia, osteoarthritis, chronic pain, and a left femur fracture, discrepancies were found between the times documented in the electronic medical record and the facility's after-hours provider notification records regarding falls and subsequent provider notifications. The Corporate Nurse was unable to explain why the times did not match and acknowledged the documentation was not accurate. For another resident with quadriplegia, chronic pain, anxiety, and depression, significant gaps were identified in the Activities of Daily Living (ADL) flow sheet documentation. Missing entries were noted for bathing, bed mobility, dressing, hygiene, toileting, and eating over an eleven-day period. The DON confirmed that the documentation was unacceptable and attributed the issue in part to agency staff not having access to the electronic medical record, as well as the resident's short stay at the facility.
Failure to Accurately Complete PASARR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected a resident's diagnosis of major depressive disorder. According to the facility's policy, the Social Worker or designated staff are responsible for ensuring that all patients with mental disorders receive appropriate pre-admission screenings in accordance with federal and state regulations. Record review showed that a resident was admitted with diagnoses including liver disease, dementia, and major depressive disorder. The resident's Minimum Data Set (MDS) assessment documented symptoms consistent with depression, such as little interest or pleasure in activities, feeling down, poor appetite, low energy, trouble concentrating, and impaired memory and decision-making. The MDS also indicated a moderate cognitive impairment and specifically noted depression as a psychiatric/mood disorder. Despite this documented diagnosis and symptoms, the PASARR Level I Identification Screening completed for the resident indicated that the resident did not have a diagnosis of or a suspected mental illness. During an interview, the Social Services Director confirmed that the PASARR screening was incorrect and acknowledged that staff should have documented the resident's diagnosis of major depressive disorder.
Delayed Hospital Transfer Following Resident Fall with Injury
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, osteoarthritis, chronic pain, and a previous left femur fracture experienced a fall resulting in pain to the left shoulder and left groin area. Documentation showed that the resident's pain level increased from 2 to 5 on a 1-10 scale following the fall, and later reached a 7. Despite these symptoms and visible signs of distress, there was a significant delay in sending the resident to the hospital. X-rays were ordered but not completed until later in the day, eventually revealing a displaced fracture of the left femoral neck. The resident was not transferred to the hospital until after the abnormal x-ray results were obtained. Interviews with staff indicated confusion and lack of timely communication regarding the fall and the resident's condition. The unit manager and DON both stated they were not promptly notified of the incident, and an LPN expressed concern about the delay in assessment and intervention, noting that the resident was visibly in pain and her hip appeared abnormal. The delay in response and transfer to the hospital resulted in the resident remaining in pain for an extended period before receiving appropriate medical care.
Failure to Ensure Proper Inflation of Specialized Air Mattress
Penalty
Summary
A deficiency occurred when a resident with reduced mobility, legal blindness, type 2 diabetes mellitus, and morbid obesity was found sleeping on a deflated alternating air mattress. The resident's medical records and provider orders indicated the need for a specialty alternating air mattress to prevent or treat pressure injuries. The care plan also documented the use of this therapeutic mattress. However, during an observation, the mattress was found to be off, deflated, and without any power lights while the resident was in bed. Interviews with facility staff confirmed that the mattress was not properly inflated. An LPN acknowledged that the deflated mattress could cause entrapment or additional pressure wounds and stated that all nursing staff were responsible for checking resident care equipment. The DON also stated that it was her expectation for nursing staff to check equipment during daily rounds and that malfunctioning equipment could lead to negative outcomes for residents. The failure to ensure the resident's air mattress was properly inflated constituted the deficiency.
Failure to Date Oxygen Humidifier for Resident Receiving Respiratory Care
Penalty
Summary
Staff failed to properly maintain respiratory care equipment for a resident with congestive heart failure and anemia by not dating the oxygen humidifier bottle attached to the resident's oxygen concentrator. Facility policy required staff to label oxygen humidifiers with the date and replace disposable oxygen equipment every seven days. Provider orders also specified that oxygen components should be changed and labeled with the date and initials as needed and every week for infection control. During observation, the resident's oxygen humidifier was found undated, and interviews with nursing staff and the DON confirmed that the humidifier should have been dated and replaced according to policy and orders.
Failure to Dispose of Completed Medication as Required
Penalty
Summary
Staff failed to dispose of a completed medication for a resident after the prescribed treatment period had ended. Specifically, a resident had an order for artificial tears to be administered every two hours as needed for seven days, with a documented end date. After the order was completed, the medication was not removed from the medication cart as required by facility policy. During an observation, an opened and used bottle of artificial tears was found in the medication cart, and a Certified Medication Aide confirmed it belonged to the resident and should have been disposed of after the order ended. Further review showed that the facility's Medication Disposal Form did not include documentation of the completed artificial tears for this resident. Interviews with staff revealed that the nurse responsible for destroying discontinued medications did not receive the completed eye drops, and the DON stated that completed medications should not be kept in medication carts. The facility's policy requires discontinued medications to be promptly removed and documented, which was not followed in this instance.
Failure to Ensure Routine Dental Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental care as required. Record reviews showed that the resident had not received annual dental services, with the last documented dental visit occurring nearly two years prior. Although there was a provider order for a dental appointment, there was no documentation that the resident attended the appointment, and the order was later discontinued. Interviews with the resident confirmed that she had not received dental services in a while and was experiencing dental pain. Further investigation revealed that the facility's process for arranging dental appointments was unclear and inconsistently followed. The facility's driver was primarily responsible for tracking and scheduling dental appointments, with occasional input from social services and nurse managers. However, both the Social Services Director and Nurse Manager were unaware that the resident had missed annual dental appointments. The Director of Nursing clarified that the responsibility for arranging dental appointments should have been shared by the Interdisciplinary Team, not solely the driver.
Failure to Maintain Resident Wheelchair in Safe Condition
Penalty
Summary
A resident with a history of repeated falls, generalized muscle weakness, and a need for assistance with personal care was observed sitting in a wheelchair that was not maintained in safe operating condition. The back bar of the wheelchair was detached and hanging on one side, and the resident reported that the wheelchair had been broken for an extended period. The resident's care plan included interventions for assistance with activities of daily living, transfers, and mobility due to limited mobility. A Licensed Practical Nurse noticed the broken wheelchair and verbally informed the night nurse to notify therapy staff, but did not document the issue in the resident's progress notes. The Physical Therapist stated that staff were expected to submit a work order in the maintenance reporting system to repair the wheelchair and to place the resident in a different wheelchair until repairs were completed. The therapist confirmed that the wheelchair was missing a securing knob and was unsafe for use.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to inform residents and their representatives in writing about room changes due to a flooding event on the 200 wing. This affected eight residents who were moved without receiving written notification, including the reason for the change. Interviews with staff, including a Nurse Manager and the Director of Nursing (DON), revealed that while families were notified by phone, there was no written documentation provided to the residents or their representatives. The flooding began on 01/06/25, and residents were moved on the same day, but written notifications were not issued. Record reviews for several residents showed a lack of documentation regarding written notifications for room changes. For instance, one resident's medical record indicated that the resident was moved for safety reasons due to a plumbing issue, and the resident's Power of Attorney (POA) was notified by phone, but not in writing. Another resident's POA stated they were not informed of the room change and would have liked to know what was happening. The DON confirmed that while phone notifications were made, written notifications were not provided, which is a requirement for room changes.
Failure to Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that staff documented the medication refrigerator temperatures in the medication storage room. This deficiency was identified through record review, observation, and interviews. Specifically, the temperature log book for the medication #1 refrigerator, medication #2 refrigerator, and the specimen refrigerator showed that staff did not document temperature recordings for several dates, including the evening of 06/21/24, both morning and evening of 06/22/24, and both morning and evening of 06/23/24. During an observation on 06/24/24, it was noted that the medication storage room contained insulin and other medications requiring refrigeration. The Director of Nursing (DON) confirmed in an interview that staff are required to check and document the refrigerator and freezer temperatures twice daily to ensure they remain within the range of 36 to 46 degrees Fahrenheit, which is necessary to preserve temperature-controlled medications and specimens.
Failure to Serve Meals According to Dietary Meal Tickets
Penalty
Summary
The facility failed to ensure that residents received meals according to their dietary meal tickets, which are individualized descriptions of what staff should serve each resident. This deficiency was observed in three residents. One resident, who was supposed to receive double portions of all items, reported not getting enough food and was observed receiving only single portions, missing items like ice cream. The Regional Dietary Manager confirmed that the resident should have received double portions as per the meal ticket. Another resident provided meal tickets for May and June, noting missing items on each ticket and stating that complaints to the Dietary Manager had not resolved the issue. The resident's meal tickets showed multiple instances where items were missing from her food tray, including margarine, jelly, sugar, eggs, and more. Additionally, the resident was served meals that did not match the menu, such as receiving Mexican spiced chicken instead of the listed cowboy casserole. The Regional Dietary Manager acknowledged these discrepancies. A third resident reported that the food rarely matched the menu, leading her to obtain food from outside the facility.
Failure to Repair Resident's Bathroom Doorknob
Penalty
Summary
The facility failed to maintain a homelike environment by not repairing a broken doorknob for a resident's bathroom door. The deficiency was observed when the resident reported that the doorknob had been broken for several weeks, preventing access to the restroom. The resident, who was continent and able to toilet independently, had informed the CNAs about the issue. A work order for the doorknob replacement was submitted on 06/17/24, but the repair had not been completed by the time of the survey. The facility's administrator was unaware of the work order's status and mentioned that the maintenance director was unavailable due to a medical emergency during the period the work order was submitted.
Inaccurate Care Plan for Resident's Smoking Status
Penalty
Summary
The facility failed to ensure the comprehensive care plan was accurate for a resident reviewed for care plan accuracy. The care plan for the resident, dated June 4, 2024, included conflicting focus areas regarding smoking. Initially, the care plan stated that the resident may not smoke per a smoking evaluation initiated on February 26, 2023. However, it was later updated to indicate that the resident may smoke with supervision per a smoking evaluation initiated on May 5, 2023. During an interview on June 28, 2024, the Director of Nursing (DON) confirmed that the resident did not smoke and had no history of smoking, indicating that neither smoking statement should have been included in the care plan.
Care Plan Revision Deficiency for UTI Risk
Penalty
Summary
The facility failed to accurately revise the comprehensive care plan for a resident who was reviewed for care plans. The resident had an active urinary tract infection (UTI) and was at risk for sepsis, as noted in the care plan dated June 4, 2024, with the condition initially identified on February 10, 2024. However, a review of the resident's quarterly Minimum Data Set (MDS) dated May 22, 2024, indicated that the resident did not have a UTI in the past 30 days. During an interview on June 28, 2024, the Director of Nursing (DON) confirmed that the resident had a UTI in February 2024 but had not had one since. The DON acknowledged that the care plan should have been updated to reflect that the resident was at risk for developing UTIs, rather than indicating an active UTI.
Failure to Obtain Wound Care Orders for Resident with Pressure Sores
Penalty
Summary
The facility failed to meet professional standards of quality by not obtaining wound care orders for a resident with pressure sores. The resident was admitted with wounds on the left heel and right big toe, and later developed a stage II pressure wound on the sacrococcygeal area. Although the wound care nurse documented the sacral wound and an order was put in place on 12/16/23, the treatment administration record (TAR) did not reflect this order, leading to confusion and lack of documented wound care for the sacral wound. The Director of Nursing and the wound care nurse were unclear why the order did not appear on the TAR, despite conversations indicating that wound care was being completed. The issue was further complicated when a nurse found multiple wounds on the sacrum during a routine check and noted that the resident's tail bone was red and inflamed due to bowel movements. The Unit Manager confirmed that orders need to be in place for treatment to occur and that any discrepancies should be addressed by obtaining the necessary orders. A CNA also confirmed that the resident always had a dressing on the sacrum, but the lack of proper documentation and orders on the TAR led to inconsistencies in wound care management.
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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