Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fiesta Park Wellness & Rehabilitation during CMS and state inspections, most recent first.
Failure to Supervise Nursing Student During Meal Delivery: A nursing student delivered a breakfast tray to a resident with an active NPO order after being directed by a CNA, without verifying the resident’s identity or diet order. The resident, who had dysphagia, PEG dependence, aspiration pneumonia, and acute respiratory failure with hypoxia, consumed part of the meal before staff removed the tray. The resident later developed chest congestion, low O2 saturation, worsening lung sounds, and was transferred to the ER with findings concerning for aspiration or multifocal pneumonia.
A resident with a femur fracture, impaired mobility, and a BIMS score of 15 reported that a CNA entered her room appearing unsteady, touched and rubbed her arm in a sexual manner, and ate part of her hamburger from her meal tray. She became tearful, reported fear and discomfort, had sleep disturbance and depressive symptoms, and staff later found the CNA unresponsive in a locked restroom with signs of alcohol or substance use.
Failure to Timely Report Allegation Involving NPO Resident: A resident with aspiration pneumonia, respiratory failure, dysphagia, and PEG dependence was given a regular breakfast tray by a nursing student despite NPO orders. The resident consumed bacon and eggs before the tray was removed, later became unresponsive, and was sent to the ER. The facility did not submit the incident summary to the SA without delay, and the Administrator stated the report should have been made when the event occurred but was not submitted until several days later.
A resident with muscle weakness, difficulty walking, and on renal dialysis was transported to an appointment when the facility van driver failed to fully secure the wheelchair, contrary to the facility’s vehicle safety policy requiring all wheelchairs to be tied down and EMS contacted after an accident if needed. As the van accelerated from a stop, the unsecured front of the wheelchair allowed it to tip backward, causing the resident to fall, hit her head, and experience immediate severe neck and back pain. The resident reported repeatedly asking the driver not to move her and to call an ambulance, but the driver instead moved her, did not call 911, and continued to the dialysis clinic. At the clinic, staff later arranged EMS transport to the hospital, and the resident was found to have whiplash and a fractured fifth metatarsal with ongoing pain.
Open Outdoor Dumpster Left Uncovered: An outside trash dumpster was observed with its lid left open on two occasions, exposing waste material to the environment. The DM stated the dumpster should remain closed when not in use and that leaving it open could attract pests.
Incomplete consent forms were found for vaccinations and psychotropic medications. Three residents had vaccination consent forms that were missing required signature, date, and time information, and two residents had psychotropic medication consent forms for antidepressant medications that lacked the resident or POA signature. The DON stated consents were often obtained verbally, while the ADON and Infection Preventionist stated the vaccination consent signature line must be completed for the form to be valid.
Inaccurate and Incomplete MDS Assessments: The facility failed to ensure two residents’ MDSs were accurate and complete. One resident with dementia, cognitive impairment, dysphagia, and muscle wasting was documented as having clear speech even though nursing notes and an LPN and CNA described the resident as non-verbal. Another resident’s re-entry MDS was missing the mood and mood interview section, which the MDS Coordinator, DON, and Administrator stated should have been completed.
A resident admitted with UTI and urinary retention had a Foley catheter in place, and the MDS and TAR documented ongoing Foley catheter care every shift. However, the baseline care plan did not include Foley catheter use or related interventions, and the DON confirmed it should have been included.
Medication security and storage failures were observed when an unlocked narcotic box was found in a med cart, medications were pre-poured and left in the cart for future use, and a loose oral tablet was found on the floor in the 200-unit. An LPN, CMAs, ADON, and DON all stated medications and controlled substances should be secured, not pre-poured, and not left unattended or out of packaging.
Failure to implement fall care plan interventions for a resident at risk for falls related to generalized weakness and impaired mobility. The care plan included interventions such as non-skid footwear, call light assistance, waiting for staff before transfers, and use of assistance while wearing an orthopedic boot, but a CNA and an LPN stated no fall precautions were in place and that new interventions after prior falls were not implemented.
A resident with spinal stenosis, muscle weakness, and ADL assistance needs was transferred with a Hoyer lift, but the care plan did not include that transfer method. CNAs were observed using the lift, the resident stated staff used it for bed transfers after becoming significantly weakened following a recent infection, and an LPN confirmed the resident required two-person assistance and a Hoyer lift. The DON acknowledged the lift use should have been care planned.
A resident with ESRD had physician orders and the care plan listing dialysis for Monday, Wednesday, and Friday at 6:00 am, but the resident stated dialysis was actually occurring on Tuesday, Thursday, and Saturday at 11:45 am. The DON confirmed the dialysis schedule had changed and that the orders and care plan should have been updated to match the new schedule.
A resident with a foley catheter due to neurogenic bladder was observed in a wheelchair with the urinary catheter bag dragging on the floor while being pushed to activities. An LPN stated catheter bags should be secured below the bladder and not touch the ground, and the DON stated the bag should not be dragging or laying on the floor.
The facility failed to accurately complete PASARR Level I screenings for multiple residents with documented mental health diagnoses, including major depressive disorder, depression, and anxiety disorders. Despite these diagnoses being listed on admission face sheets, staff marked on the PASARR forms that the residents did not have mood, anxiety, psychotic, or related mental health conditions. The SSD reported there was no systematic process to review incoming PASARRs for accuracy and acknowledged that her department had not been reviewing these screenings, resulting in multiple inaccurate PASARRs for residents requiring mental health-related assessment.
Staff failed to maintain a safe oxygen storage area on one unit when the oxygen storage room door lock was nonfunctional, allowing the door to be opened without an access code, and portable O2 cylinders were observed sitting on the floor instead of in the designated cylinder rack. Facility policy required oxygen cylinders to be secured in a cart or bracket and stored in clean, dry locations. The Central Supply Manager acknowledged that all oxygen equipment must be stored in proper areas for safety and that improper storage could create a hazard, and the Administrator stated the oxygen storage room was expected to remain locked at all times when not in use but was unaware the keypad lock was not working.
Facility staff failed to complete an accurate discharge MDS for a resident when the discharge destination was left blank. The resident, who had diagnoses including Guillain-Barre syndrome, epilepsy, and depression, became unable to transfer out of bed and was transported by ambulance to a hospital for evaluation after a change in condition. Documentation in the medical record, including a change in condition form and progress note, showed the resident was sent to the hospital, and the DON confirmed the resident had been scheduled for discharge that day. The MDSC, who was responsible for the assessment, acknowledged that the resident was discharged to the hospital and that the discharge MDS was inaccurate because the discharge destination was not coded.
During a flooring renovation project, several residents were removed from their rooms without prior notice and were left for extended periods in wheelchairs or crowded into another room, with one resident moved from a bariatric bed with rails to a smaller standard bed without rails. Residents reported having no access to their own bathrooms, belongings, or a place to lie down, and some observed others sleeping on couches in common areas while construction workers replaced flooring in their rooms. The Administrator acknowledged the facility-wide flooring replacement and stated no complaints had been received, without indicating that residents were given notice or options before being told to leave their rooms.
During a flooring renovation, the facility failed to follow its own safety plan and manufacturer guidance for flooring adhesive, leaving multiple uncovered buckets of industrial adhesive in resident areas and applying adhesive in an open resident room without fans, open windows, or open exit doors, resulting in strong odors throughout the hallway while residents remained in nearby rooms. A visitor reported a strong, unpleasant odor despite wearing a mask, and a resident with asthma expressed concern. Review of the adhesive’s MSDS showed the need for adequate ventilation and keeping containers closed when not in use, but facility leadership believed residents were not at risk and relied on existing mechanical ventilation. At the same time, surveyors observed extensive obstruction of multiple means of egress, including resident hallways, utility and kitchen dock corridors, and the Administration wing, where beds, carts, equipment, furniture, boxes, and other items blocked or encroached on exit paths and doors while residents in wheelchairs navigated around them. A resident reported being displaced from his room for flooring work and stated that hallway items had been present, moved, and then returned, and that the hallway had been in this condition for some time.
A resident admitted after a recent defibrillator implant did not receive an initial skin assessment upon admission. The LPN responsible did not remove the resident's clothing to check for bruising or surgical sites, citing the resident's fatigue and a busy unit. No documentation of the assessment was made, and the DON confirmed the assessment was missing from the medical record.
A resident's medical record was not updated with the correct hospital discharge orders for IV antibiotics, resulting in early discontinuation and a delay in restarting the medication. The updated orders were received and used by an LPN but were not uploaded into the EMR, leaving only outdated information available for review.
The facility failed to maintain sanitary conditions in food storage and handling, with unlabeled and undated food items in the refrigerator and freezer, improper storage of a flour scoop, and thawing of meats in stagnant water. Additionally, a dietary aide was observed not wearing a hairnet, and meat was stored on the kitchen floor. These practices could affect all 107 residents and lead to foodborne illnesses.
The facility failed to conduct a required quarterly care plan meeting for a resident and did not update care plans for two residents to reflect changes in medical management, including the use of a Libre2 glucose monitor and oxygen therapy. The omissions were confirmed by facility staff.
A resident in a long-term care facility did not receive appropriate care due to a lack of communication and implementation of medical orders. The facility failed to inform a PA about the discontinuation of Sodium Zirconium for hyperkalemia, leading to its continued inclusion in the treatment plan. Additionally, a nephrologist's recommendation for a potassium binder was not timely implemented. The facility also did not follow orders to use a Libre2 glucose monitor, continuing with finger sticks due to staff not being notified of the new order.
A facility failed to ensure proper communication and documentation for a resident receiving dialysis. Despite a policy requiring dialysis communication forms to be completed and stored in the resident's EHR, several forms were missing. Staff interviews confirmed the importance of these forms for monitoring the resident's condition, yet they were not consistently completed, leading to a deficiency in care management.
The facility failed to maintain a medication error rate below 5%, with a 50% error rate observed. Two residents received medications significantly later than the scheduled time of 7:00 am, with administration occurring at 8:40 am and 8:55 am. The CMAs acknowledged the delay, and the ADON confirmed the requirement for timely administration within one hour of the scheduled time.
The facility failed to maintain accurate medical records for seven residents by not ensuring that pharmacist recommendations were reviewed and acknowledged by providers. The Assistant Director of Nursing claimed to have conducted telephone reviews with providers, but the documentation lacked necessary signatures and details as per the facility's policy, potentially impacting residents' medication needs.
A resident reported $150.00 missing from under her mattress, but the facility failed to document or investigate the incident. The resident informed the Administrator, who acknowledged the report but did not pursue further investigation after the resident declined to file a formal grievance or police report.
A resident with spina bifida and pressure ulcers was discharged from an LTC facility without confirmed home health services due to non-payment. The facility failed to verify acceptance of the referral by the home health agency before discharge, leaving the resident to arrange services independently. The resident expressed frustration over the lack of communication and assistance from the facility.
A resident on a Consistent Carbohydrate (CCHO) diet did not receive a side salad with dinner as specified on their meal ticket. Despite informing nursing staff, the issue persisted, and during a dinner observation, the resident was served a meal without the side salad. Both an LPN and the Dietary Manager confirmed the oversight.
A resident on blood thinners experienced a fall resulting in a head laceration, but the facility delayed sending her to the ER for several hours. Despite significant bleeding and the resident's medication increasing bleeding risk, staff confusion led to a delayed response. The resident required staples for the head injury once finally treated in the ER.
Failure to Supervise Nursing Student During Meal Delivery
Penalty
Summary
The facility failed to provide adequate oversight of nursing students when a nursing student delivered a regular breakfast tray to a resident who had an active NPO order. The resident had been admitted with diagnoses including aspiration pneumonia, acute respiratory failure with hypoxia, dysphagia, and PEG dependence. The resident’s care plan directed staff to provide tube feeding related to dysphagia, and physician orders included NPO status and continuous enteral feeding. On the morning of the incident, the nursing student was assisting with meal tray delivery and was directed by a CNA to deliver a tray to a resident room. The student delivered the tray to the wrong room, where the resident with the NPO order lived. The student did not verify the meal ticket, the resident’s identity, or the resident’s diet order before delivering the meal. The resident consumed some bacon and eggs before staff identified the error and removed the tray. After the meal was delivered, staff documented that the resident developed chest congestion and had oxygen saturation levels in the 80s, requiring supplemental oxygen. The provider was notified, a chest x-ray was ordered, and the resident later became unresponsive with congested lung sounds. The resident was transferred to the emergency room, where hospital documentation noted shortness of breath, increased oxygen needs, and chest x-ray findings concerning for aspiration or multifocal pneumonia. Interviews also showed the nursing student instructor was supervising multiple students on the unit but was not physically present with each student during meal tray delivery, and the facility did not provide a facility-specific orientation before the students began clinical rotation.
Unwanted Contact and Meal Tray Incident
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a CNA engaged in unwanted physical contact and ate food from the resident’s meal tray. The resident had been admitted with a displaced fracture of the lower end of the left femur, impaired mobility, and weakness, and her MDS discharge assessment showed a BIMS score of 15, indicating she was cognitively intact. She used a wheelchair for mobility and required assistance with transfers. The resident reported that the CNA entered her room after dinner appearing unsteady, leaning, hovering, and moving side to side, and that he touched and rubbed her shoulder and moved his hand down her arm. She stated he grabbed her meal tray, took a bite from her hamburger, and left the room, and that she felt uncomfortable, scared, violated, and trapped. Nursing notes documented that she was tearful, did not sleep well after the incident, and reported feeling down, depressed, or hopeless, with difficulty sleeping and concentrating. Staff interviews confirmed the resident’s report, including that she was concerned about retaliation and that the CNA was later found unresponsive in a locked restroom with signs of alcohol or substance use.
Failure to Timely Report Allegation Involving NPO Resident
Penalty
Summary
The facility failed to submit the required incident summary report without delay to the State Agency for a resident involved in an allegation of abuse/neglect. The facility’s abuse prevention program policy, revised 10/24/22, states that staff must promptly and thoroughly investigate reports of abuse, mistreatment, neglect, injuries of unknown origin, or criminal acts, and that allegations of abuse or neglect that do not result in serious bodily injury must be reported no later than 24 hours after forming the suspicion. Record review showed the resident was admitted with aspiration pneumonia, respiratory failure, dysphagia, and PEG dependence. The incident report dated 06/10/26 stated that on 06/06/26 a Nursing Student provided the resident with a regular breakfast tray despite physician orders for NPO status, and the resident consumed portions of bacon and eggs before the error was identified and the tray removed. The resident became unresponsive and was discharged to the ER on 06/08/26. During interview, the Administrator stated he first became aware of the incident on 06/10/26 during the morning meeting and that the incident should have been reported to the State Agency on 06/06/26, but it was not submitted until 06/10/26.
Failure to Secure Wheelchair and Obtain EMS After Transport Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during transport in the facility van. The facility’s Vehicle Safety Program Policy directed authorized employees to operate company vehicles safely, ensure all occupants used seatbelts prior to moving the vehicle, ensure all wheelchairs were tied down securely before moving the vehicle, and check for injuries and call Police/EMS if needed in the event of an accident. Despite this policy, the facility van driver did not fully secure the resident’s wheelchair before transport. The resident, who had diagnoses including muscle weakness, difficulty walking, and renal dialysis, was being transported to a dialysis appointment when the incident occurred. Record review showed that during transport, the resident’s wheelchair tipped backward in the van when the driver accelerated near the dialysis clinic. The driver had secured the back straps of the wheelchair but failed to secure the front straps before leaving the facility. When the light turned green and the van accelerated, the resident rolled backward in the wheelchair and fell. The driver then pulled over and assessed the resident, determining on his own that there were no injuries, and moved the resident. The resident reported that she hit her head, experienced immediate pain in her neck and back, and rated her pain as 10 out of 10. She stated that she told the driver multiple times not to move her and to call an ambulance. Despite the resident’s repeated requests, the driver did not call 911 and instead continued the transport to the dialysis clinic. The resident remained on the floor of the van for several minutes before the driver attempted to lift her. At the dialysis center, the resident became upset and asked staff to send her to the hospital. Dialysis staff monitored her and then called 911 for transport to the hospital. Subsequent documentation indicated the resident developed bruising to her right foot, later associated with the fall, and was diagnosed with a fractured fifth metatarsal, as well as experiencing whiplash and ongoing pain in her neck, back, and foot. The Administrator and DON acknowledged that the driver failed to properly secure the wheelchair and that the wheelchair tipped over during transport.
Open Outdoor Dumpster Left Uncovered
Penalty
Summary
The facility failed to ensure the outdoor trash dumpster was covered to minimize odors and prevent pests or rodents. On 04/14/26 at 2:14 PM, an observation found an outside trash dumpster with its lid left open, exposing waste material to the environment. On 04/20/26 at 9:47 AM, another observation found the outside dumpster unattended with its lid left open, again leaving waste material accessible to the environment. During an interview on 04/20/26 at 9:50 AM, the Dietary Manager stated the outside dumpster should remain closed when not in use and that leaving it open could attract pests.
Incomplete Consent Forms for Vaccinations and Psychotropic Medications
Penalty
Summary
Vaccination consent forms were not properly completed for three residents. Record review showed that the vaccination consent forms for R #12, R #74, and R #129 were undated and lacked information in the signature, date, and time sections, and the provider notification of vaccination refusal section was also incomplete. The DON stated that vaccination consents were mostly obtained verbally by nursing staff, but the resident or representative name should be typed in the box if not signed in person, and stated that the forms for these residents were incomplete and should have been completed. The ADON and Infection Preventionist stated that the signature line of the vaccination consent form must be completed for the form to be considered valid. Psychotropic medication consent forms were not signed by the resident or their POA for two residents. R #3 had physician orders for Trazodone HCl 50 mg at bedtime for depression and Sertraline HCl 50 mg daily for depression/anxiety, and the psychotropic consent form documented that consent was obtained in person/written but lacked the resident or POA signature. R #13 had a psychotropic consent form for Bupropion ER 100 mg that also documented consent was obtained in person/written but lacked the resident or POA signature. The DON stated the consent forms were mostly obtained verbally but the resident or representative name should be typed in the box if not signed in person, and stated the forms for R #3 and R #13 were incomplete and should have been completed. The ADON stated that the signature line of the psychotropic medication consent form must be completed for the form to be considered valid.
Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure the MDS was accurate for 2 residents reviewed for MDS accuracy. For one resident with diagnoses including dementia, cognitive impairment, dysphagia, and muscle wasting/atrophy, the Comprehensive MDS and Quarterly MDS documented clear speech even though nursing progress notes described the resident as non-verbal and unable to answer questions as her baseline. During interviews, a CNA and an LPN both stated the resident was non-verbal, and the MDS Coordinator stated the MDSs were documented incorrectly and that the resident was non-verbal despite the MDS indicating clear speech. For the second resident, the re-entry MDS did not have the mood and mood interview section completed by facility staff. The MDS Coordinator stated the resident was not assessed for mood on the MDS and should have been, and identified Social Services as responsible for completing the mood assessment while the MDS Department was responsible for ensuring the MDS was completed. The DON and the Administrator also stated the mood assessment should have been completed but was not.
Incomplete Baseline Care Plan for Foley Catheter Use
Penalty
Summary
The facility failed to develop and implement an adequate baseline care plan for one resident within 48 hours of admission. The resident was admitted with diagnoses of UTI and urinary retention, and the admission MDS showed the resident had a Foley catheter. The March 2026 TAR also documented Foley catheter care every shift, and the resident required the Foley catheter due to chronic urinary tract infections. The resident’s baseline care plan, dated 03/26/26, did not include Foley catheter use or related interventions. During an interview, a CNA stated the resident had a Foley catheter when admitted to the facility. The DON later stated the resident had a Foley catheter in place during the stay and that Foley catheter use should have been included in the baseline care plan.
Medication Security and Storage Failures
Penalty
Summary
The facility failed to ensure proper storage and security of medications in medication carts. During observation, the narcotic box in a medication cart in the 200-unit behind the nurse's station was found unlocked and could be easily opened, allowing access to the narcotic medications stored inside. An LPN stated the narcotic box should always be locked and reported that it was not locking properly and had been reported to the pharmacy two days earlier. The DON stated the narcotic box should be secured behind two locks at all times when not in use and said she had been informed the box was not locking the day before the observation. The facility also failed to prevent medications from being pre-poured and left in medication carts. A CMA was observed removing lidocaine patches from packaging, dating and initialing them, and placing them in the medication cart for future use. Another CMA was observed preparing medications, then placing the prepared medication in the top drawer of the medication cart, locking the cart, and leaving to obtain a nutritional shake. Both CMAs stated medications should not be pre-poured or left in the cart in advance of administration, and the DON stated it was her expectation that medications are not pre-poured and should not be left in the cart while staff step away. In addition, a small round peach-colored oral tablet with imprint H1 was observed lying on the floor in the 200-unit between rooms 215 and 216, with no staff present nearby. The ADON and DON both stated the tablet should not have been left on the floor and that medications were expected to remain secured at all times.
Failure to Implement Fall Care Plan Interventions
Penalty
Summary
The facility failed to ensure care plan interventions were implemented for a resident who was at risk for falls related to generalized weakness and impaired mobility. The resident was admitted on [DATE] and had Change in Condition assessments completed for falls on 04/07/26 and 04/09/26. The care plan dated 04/10/26 included fall interventions added after the falls, including re-education to be patient and wait for staff to assist on and off the toilet, provision of non-slip socks, education to call for assistance when transferring, and instruction to use assistance while wearing an orthopedic boot. During interviews, a CNA stated the resident did not have any fall precautions in place to prevent falling. An LPN stated the resident did not have any fall precautions and reported there were not any new interventions implemented following the prior falls on 04/07/26 and 04/09/26. The LPN also stated management was responsible for updating care plans and informing nursing staff of new interventions, and that nursing staff relied on management to communicate changes. The DON stated the resident’s fall interventions included non-skid footwear, call light assistance, and instruction to wait for staff before transferring, and stated she added new fall interventions to the care plan after each fall.
Care Plan Did Not Reflect Hoyer Lift Transfers
Penalty
Summary
The facility failed to revise the care plan for a resident whose admission diagnoses included spinal stenosis, muscle weakness, and need for assistance with personal care and ADLs. The resident’s care plan, dated 12/30/2025, did not include the resident’s use of a Hoyer lift for transfers, even though the resident required that equipment for mobility assistance. During observation on 04/14/2026, two CNAs were seen using a Hoyer lift to transfer the resident from bed to wheelchair. In interviews, the resident stated nursing staff used a Hoyer lift to transfer her in and out of bed and that after a recent infection she became significantly weakened and needed increased assistance. An LPN stated the resident required two-person assistance for transfers and used a Hoyer lift. The DON stated it was her expectation that all residents who use a Hoyer lift are care planned according to their needs and acknowledged that the resident’s Hoyer lift use should have been care planned but was not.
Dialysis Schedule Not Updated in Orders and Care Plan
Penalty
Summary
The facility failed to provide quality care that met professional standards for one resident with end stage renal disease. Record review showed the resident’s active physician orders and care plan, both dated 12/22/25, listed dialysis for Monday, Wednesday, and Friday at 6:00 am. However, during an interview on 04/14/26, the resident stated that dialysis was actually being received on Tuesday, Thursday, and Saturday at 11:45 am. During a later interview on 04/20/26, the DON stated that the resident’s dialysis schedule had changed and that the physician orders and care plan should have been updated to reflect the new schedule.
Urinary catheter bag dragged on the floor
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 1 resident. R #10 was admitted to the facility with a care plan dated 04/13/26 indicating use of a foley catheter due to neurogenic bladder. During an observation on 04/15/26 at 11:23 AM, R #10 was seen sitting in a wheelchair while being pushed to activities by a facility staff member, and the urinary catheter bag was dragging on the floor. During interviews, an LPN stated the catheter bag should be secured below the bladder and should not touch or drag on the ground because it presents a risk of infection, and the DON stated the bag should be secured below the bladder and not be dragging or laying on the floor because the bag could open and present a risk of infection.
Inaccurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I screenings for multiple residents with documented mental health diagnoses. Record review showed that several residents were admitted with diagnoses such as major depressive disorder, depression, and anxiety disorders, yet their PASARR Level I forms indicated that they did not have mood, anxiety, or other qualifying mental health conditions. For example, one resident admitted with major depressive disorder had a PASARR Level I dated the same day of admission that documented no mood, panic, anxiety, personality, psychotic, depression, or substance-related disorders. Similar discrepancies were identified for additional residents. Another resident admitted with major depressive disorder had a PASARR Level I completed the day prior to admission that incorrectly indicated no mood or depression-related diagnoses. Residents with documented anxiety disorders also had PASARR Level I screenings that stated they did not have anxiety, mood, or related mental health conditions. Multiple residents with diagnoses of depression or major depressive disorder had PASARR Level I screenings completed on or near their admission dates that failed to acknowledge these conditions, instead marking that no such mental health diagnoses were present. During an interview, the Social Services Director reported that the facility did not have a systematic process in place to review incoming PASARRs as part of the admission screening process. The Social Services Director stated she had only recently been informed that reviewing resident PASARRs was the responsibility of her department and acknowledged that PASARRs were not being reviewed for accuracy. She confirmed that the PASARRs for all identified residents were inaccurate and stated that they should have reflected the residents’ documented mental health diagnoses.
Failure to Secure Oxygen Storage Room and Properly Store Oxygen Cylinders
Penalty
Summary
Facility staff failed to maintain a safe oxygen (O2) storage environment on the 200-unit by not securing the oxygen storage room and not properly storing oxygen cylinders. Record review of the facility’s Oxygen Administration Policy dated 06/2020 showed that oxygen cylinders were required to be secured in a cylinder cart or bracket at all times and stored in clean, dry locations. On observation, the oxygen storage room keypad door lock on the 200-unit was without power, nonoperational, and its screen remained blank and did not activate when touched, allowing the door to be opened without entering an access code. Additional observation showed portable medical oxygen cylinders sitting on the floor instead of being stored in the designated oxygen cylinder rack. In interviews, the Central Supply Manager stated that all oxygen equipment, including portable oxygen tanks, must be stored in proper storage areas for safety and that improper storage could create a hazard, and the Administrator stated the oxygen storage room should remain locked at all times when not in use and acknowledged she was not aware the keypad lock was not functioning and that the door could be opened without a code. No specific residents or their medical histories were identified in the report; the deficiency pertained to the general safety of the oxygen storage area accessible to residents, staff, and the public.
Inaccurate Discharge MDS Due to Omitted Discharge Destination
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the discharge MDS did not include the resident’s discharge destination. The resident had been admitted with Guillain-Barre syndrome, epilepsy, and depression, and was later unable to transfer out of bed and was sent to the hospital via ambulance for evaluation after experiencing abdominal pain. Record review showed a Change in Condition form and progress note documenting the transfer to the hospital, and the DON stated the resident had been scheduled for discharge on the same day the resident was sent to the hospital. However, the discharge MDS for that resident, completed by the MDS Coordinator, was left with the discharge destination field blank, despite the MDSC acknowledging that the resident was discharged to the hospital and that the assessment was therefore inaccurate. This deficiency was identified through record review of the face sheet, Change in Condition form, progress note, and discharge MDS, as well as interviews with the DON and the MDSC, who confirmed that the discharge destination should have been coded and that it was her responsibility to complete accurate MDS assessments.
Failure to Provide Notice and Appropriate Accommodations During Room Renovations
Penalty
Summary
Surveyors found that during a flooring renovation on the 400 hallway, multiple resident rooms were emptied of furniture and flooring while construction workers were present, yet several residents remained on the hallway and were displaced from their rooms without prior notice. One resident reported being told by staff to leave his room so carpet could be removed and flooring installed, with no advance notice, and then having to sit in his wheelchair from 7:40 a.m. to 6:00 p.m. without access to his own bathroom, belongings, or a place to lie down. Another observation showed three residents together in a single resident room, with two in wheelchairs and one lying in a standard hospital bed without rails. A resident who normally used a bariatric bed with rails stated she was moved out of her room without notice to a smaller standard bed without rails and was not told how long she would be out of her room or how staff would assist her with restroom needs, given that her required equipment remained in her original room. Another resident stated she was removed from her room at 8:00 a.m. and not allowed to return until after 7:00 p.m., with no prior notice and no place to nap, remaining in her wheelchair all day and observing other residents sleeping on couches in common areas. A third resident reported being moved out of her room without notice for flooring replacement and not being informed when she could return or where she could use the restroom privately with her wheelchair. The Administrator stated the facility was replacing flooring throughout the building and that the 400 hallway was the last area to be completed, and reported not receiving any complaints from residents during the construction, without indicating that residents had been given notice or options before being told to leave their rooms.
Inadequate Ventilation of Flooring Adhesive Fumes and Blocked Egress During Renovation
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and comfortable environment during a flooring renovation project, specifically related to inadequate ventilation of construction adhesive fumes and obstruction of the means of egress. The facility’s Safety Plan for the floor renovation, dated 09/16/2025, identified affected resident units and noted potential issues such as unpleasant odors from materials in use. The plan instructed staff to contain aerosol dust and debris with ventilation as needed, close doors where applicable to provide barriers, and remove patient activity and exposure in areas being worked on as allowable. Despite these written instructions, surveyors observed that these measures were not implemented as required during active construction. During observations on the 400 hallway, surveyors found multiple five-gallon buckets of industrial flooring adhesive uncovered and accessible in resident areas, including three buckets in an electrical closet with the door open, one bucket on a hallway table, and another on the floor. Adhesive was visible on the sides and bottoms of the buckets, and residents were moving throughout the unit around these open containers. In resident room 427, flooring adhesive had been applied to the floor with the door left open while a construction worker, who was wearing a face mask, installed flooring. There was a strong adhesive odor throughout the 400 hallway, with no fans present, windows in room 427 closed, and the exit door at the end of the hallway also closed. Residents were present in nearby rooms 423, 424, 425, and 426 with their doors open. A visitor reported smelling a strong, unpleasant adhesive odor through a face mask and suggested that closing resident room doors would help protect them from the odor. Another resident with asthma stated she could not smell the odor due to difficulty smelling but was concerned about it. Record review of the flooring adhesive’s Material Safety Data Sheet showed instructions that, if inhaled, individuals should be moved to fresh air, and that adequate ventilation and respiratory protection were recommended when using the product. The MSDS also directed that accidental releases be managed by ventilating the area and that containers be kept closed when not in use. Despite this, the Administrator stated she did not believe residents were at risk from inhalation of the adhesive vapors and reported no complaints during the renovation. The Plant Operations Manager stated that the hallway’s mechanical ventilation was considered sufficient and that exit doors on certain units should be opened if residents were uncomfortable, but these doors were not open at the time of observation. The deficiency also includes extensive obstruction of the means of egress throughout the facility during the renovation. NFPA 101, Life Safety Code, requires that means of egress be continuously maintained free of obstructions or impediments. On observation, the 400 hallway, where residents were living during renovation, had its egress path blocked by two trash cans, four beds, an armchair, three tables, a chair, three 4-gallon buckets, an industrial tile cutter, and piled boxes of wood flooring strips, while residents in wheelchairs navigated around these items. Additional egress routes were blocked in multiple areas: the Utility hallway by boxes containing wheelchairs and other items; the kitchen dock hallway by a tall food tray cart, cleaning supplies, and boxes, with double exit doors further blocked by a wood pallet and a cardboard box; and the Administration wing by numerous items including vacuums, furniture, housekeeping and floor machines, a hoyer lift, medical equipment, and stacked boxes, with an emergency exit door blocked by an oxygen cylinder, printers, and boxes. Other hallways outside resident rooms had egress paths blocked or encroached upon by unused utility carts, treatment carts, a mattress, a wheelchair, a medication cart, and service carts. A resident reported being told to leave his room for most of a day so flooring could be replaced and stated that the hallway items were present when he left his room, were moved out, and then brought back, and that the hallway had been like that for a while. The Administrator acknowledged that the Maintenance Department was responsible for maintaining the facility according to the Life Safety Code, and the Plant Operations Manager stated that means of egress should be maintained throughout the remodeling period and that staff should remove items stored within the egress paths.
Failure to Complete Initial Skin Assessment on Admission
Penalty
Summary
The facility failed to complete an initial skin assessment for one of three residents reviewed for skin assessments during the admission process. Record review showed that the resident was admitted following a recent procedure to implant a defibrillator and was later discharged against medical advice due to concerns of physical abuse, presenting with bruising, swollen genitals, penile bleeding, and various other bruises. Upon review of the resident's medical chart, no initial skin assessment was found, and the Director of Nursing confirmed that the assessment should have been completed by the admitting nurse but was not present in the records. During interviews, the LPN responsible for the admission stated that he did not perform the skin assessment because the resident was fatigued, the unit was busy, and he was occupied with paperwork and the family. The LPN admitted to not removing the resident's clothing to check for bruising or surgical sites and only noted excoriation at the tip of the penis after the resident tugged on his Foley catheter. The LPN did not document any initial assessments, nor did he inform anyone that the skin check was not completed, resulting in the lack of a trigger for follow-up by other staff.
Failure to Update and Upload Hospital Discharge Orders in EMR
Penalty
Summary
The facility failed to ensure that a resident's medical record was updated with necessary and accurate hospital discharge orders. Upon admission, the resident had been receiving intravenous (IV) antibiotics for a severe infection, with hospital discharge orders specifying that the antibiotics should continue for four weeks post-discharge. However, the facility discontinued the antibiotics earlier than ordered and did not restart them until ten days later, after the nurse practitioner identified the error and re-ordered the medication. Interviews revealed that the admitting LPN received incomplete discharge orders and had to request updated orders, which were subsequently emailed to him. Although these updated orders were used for the resident's admission and reviewed with the nurse practitioner, they were not uploaded into the electronic medical record (EMR). The EMR only contained the original, outdated discharge orders, and the updated orders were not available for review by the state agency. The Director of Nursing confirmed that the updated orders should have been uploaded but were not.
Sanitary Lapses in Food Storage and Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and handling, as observed during a survey. In the kitchen, several food items, including diced potatoes, salad mix, diced ham, ground pork, and chicken breast, were found unlabeled and undated in the refrigerator and freezer. Additionally, a flour scoop was improperly stored on top of a flour bag in the dry storage area. The Dietary Manager acknowledged these issues, confirming that all food items should be labeled and dated, and that flour scoops should be stored in a sanitary manner. Further observations revealed additional sanitary lapses, including six packs of meat stored on the kitchen floor, a dietary aide not wearing a hairnet, and packages of bologna and turkey being thawed in stagnant water instead of under running water. The Dietary Manager confirmed these findings, stating that food should not be stored on the floor, staff should wear hairnets, and frozen meats should be thawed safely. These practices potentially affect all 107 residents and could lead to foodborne illnesses if not addressed.
Failure to Update Care Plans and Conduct Required Meetings
Penalty
Summary
The facility failed to conduct a quarterly care plan meeting for a resident as required by their admission and Minimum Data Set (MDS) assessment. Despite the resident's expressed desire to participate in such meetings, neither the resident nor their emergency contact had been involved in a care plan meeting. The Social Services Assistant confirmed that the meeting should have occurred in December 2024 but did not, and there was no documentation of a care plan meeting in the resident's electronic health record. Additionally, the facility did not update the care plans for two residents to reflect changes in their medical management. One resident's care plan was not updated to include the use of a Libre2 glucose monitor for diabetic management, despite physician orders and the resident's preference to avoid finger sticks. Another resident's care plan lacked documentation of oxygen use, which was ordered to maintain oxygen saturation levels. The Assistant Director of Nursing acknowledged that these updates should have been made to the care plans but were not.
Failure to Communicate Medication Changes and Implement Diabetic Management Orders
Penalty
Summary
The facility failed to provide quality care that meets professional standards for a resident by not effectively communicating with healthcare providers and not implementing necessary medication recommendations. The resident, who was admitted to the facility, had an order for Sodium Zirconium to manage hyperkalemia, which was discontinued without proper communication to the Physician Assistant (PA). The PA continued to include Sodium Zirconium in the resident's treatment plan, unaware of its discontinuation. Additionally, the resident's nephrologist recommended starting a potassium binder medication, but this was not implemented in a timely manner, leading to a delay in the resident receiving necessary medication. Furthermore, the facility did not follow physician orders regarding the use of a Libre2 glucose monitor for diabetic management. Despite the resident's preference and a physician order to use the Libre2 device, nursing staff continued to use the finger stick method for blood glucose monitoring. This was due to a lack of awareness among the nursing staff about the new order, as it was not entered correctly to notify them. The Assistant Director of Nursing confirmed that the order should have been visible to the nursing staff, and the PA had educated the staff on using the Libre2 device when the order was placed.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident requiring dialysis services. The facility's policy mandates that nursing staff use dialysis communication records to convey information to the dialysis provider and maintain these records in the resident's Electronic Health Record (EHR). However, a review of the resident's EHR revealed missing dialysis communication forms for several dates, indicating a lapse in documentation and communication. Interviews with facility staff, including Licensed Practical Nurses and the Assistant Director of Nursing, confirmed that the dialysis communication forms are essential for monitoring the resident's condition and any changes during or after dialysis treatment. Despite the facility's policy and staff acknowledgment of the importance of these forms, the forms were not consistently completed and documented, leading to a deficiency in the resident's care management.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to ensure that medications were administered with an error rate less than 5%, resulting in a medication error rate of 50%. During observations, medications were administered to two residents, with 13 medication errors observed out of 26 medications administered. Specifically, one resident received aspirin, furosemide, gabapentin, and sertraline at 8:40 am, although these medications were scheduled for 7:00 am. Another resident received gabapentin, losartan, flomax, senna, duloxetine, fluticasone spray, magnesium, miralax, and a lidocaine patch at 8:55 am, also scheduled for 7:00 am. The Certified Medication Aides (CMAs) involved acknowledged the late administration of medications. The Assistant Director of Nursing (ADON) confirmed that medications scheduled for 7:00 am should be administered within one hour before to one hour after the scheduled time, meaning they should have been given by 8:00 am. The failure to administer medications within the prescribed time frame led to the observed medication errors.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for seven residents. The deficiency was identified through a review of monthly pharmacist recommendations for medications prescribed to these residents. The recommendations included suggestions for dose reductions, medication discontinuations, and the need for specific medication end dates. However, the documentation lacked signatures from the attending physicians or providers, indicating that the recommendations were not reviewed or acknowledged by them. The Assistant Director of Nursing (ADON2) was responsible for reviewing the pharmacist recommendations and claimed to have contacted the appropriate providers to discuss the recommendations. ADON2 considered these discussions as telephone reviews and orders, which she believed she was authorized to execute as a Registered Nurse. Despite this, the documentation did not reflect that these were telephone orders, nor did it include the necessary details such as the prescriber's signature, which is required by the facility's policy on telephone orders for medications. The facility's policy, dated June 2020, outlines the procedure for receiving telephone orders, which includes documenting the order details and obtaining the prescriber's countersignature within a reasonable timeframe. The failure to adhere to this policy resulted in incomplete documentation, as there was no indication that the providers had been contacted or that the orders had been read back to them for confirmation. This lack of proper documentation could adversely impact the residents' medication needs by not having accurate information available.
Failure to Investigate Missing Money
Penalty
Summary
The facility failed to investigate an allegation of missing money for a resident, which is a deficiency likely to result in resident financial hardship. The resident reported having $150.00 in a green baggie under her mattress, which went missing sometime in December 2024. Although she did not file a formal grievance, she verbally informed the Administrator about the missing money. The facility's records from August 2024 through January 2025 showed no documentation of this incident. The Administrator acknowledged being aware of the missing money and stated that the resident refused to file a police report or formal grievance. Despite searching for the money, it was not found, and no further investigation was conducted.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, identified as R #81, by not confirming that necessary home health services were arranged and accepted before her discharge. R #81, who had multiple diagnoses including spina bifida with hydrocephalus and pressure ulcers, was discharged due to non-payment. Despite being informed of her discharge, R #81 was not provided with confirmation of home health services, which were crucial for her ongoing care needs, particularly for managing her pressure ulcers. The facility's records indicated that a referral was made to a home health agency, HH #1, on the day of discharge, but there was no confirmation of acceptance from the agency before R #81 left the facility. Interviews revealed that HH #1 did not accept the referral due to insurance issues and passed it to another agency, HH #2, which had not received any referral. The Social Services Director assumed the referral was accepted without verification, leading to R #81 being discharged without confirmed home health support. R #81 expressed frustration over the lack of communication and assistance from the facility regarding her discharge plan. She was left to arrange for her own home health services after being discharged, as she had not been contacted by any agency to discuss her care needs. This oversight in discharge planning resulted in R #81 not receiving the necessary services immediately upon returning home, leaving her to navigate the process unassisted.
Failure to Serve Meal as Per Resident's Dietary Needs
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of a resident on a Consistent Carbohydrate (CCHO) diet, as evidenced by the staff's failure to serve the food items listed on the resident's meal ticket. The resident was supposed to receive a side salad with dinner, as indicated on the meal ticket dated 01/07/25. However, during an interview, the resident reported that the kitchen staff did not consistently follow the meal instructions, and despite informing the nursing staff, the issue persisted. During a dinner observation, the resident was served a meal without the side salad. Both a Licensed Practical Nurse and the Dietary Manager confirmed that the resident did not receive the side salad and acknowledged that it should have been provided as per the meal ticket.
Delayed Emergency Response for Resident on Blood Thinners
Penalty
Summary
The facility failed to provide appropriate interventions for a resident who experienced a fall resulting in a head laceration while on blood thinners. The resident, who was taking Apixaban, a blood thinner, fell and hit her head on a bedside table, causing a laceration and significant bleeding. Despite the severity of the injury and the resident's medication, which increased the risk of bleeding, the facility delayed sending the resident to the emergency room for several hours. The incident occurred at approximately 6:00 am, but the resident was not transported to the hospital until around 9:48 am, after EMS was contacted at 7:26 am. Interviews with staff revealed confusion and a lack of urgency in handling the situation. LPNs involved in the incident could not recall whether they called 911 or scheduled an EMS transport, which contributed to the delay. The Nurse Practitioner and Assistant Director of Nursing acknowledged that the resident should have been sent to the ER immediately due to the head injury and blood thinner use. The delay in treatment could have exacerbated the resident's condition, as the head laceration required staples to repair once the resident was finally seen in the ER.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Albuquerque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rehabilitation Center Of Albuquerque | 2.2 mi | ★★★★★ | 15 | 1 |
| Las Palomas Center | 2.5 mi | ★★★★★ | 9 | 4 |
| Spanish Trails Wellness & Rehabilitation | 3.5 mi | ★★★★★ | 13 | 0 |
| Albuquerque Heights Healthcare And Rehabilitation | 3.8 mi | ★★★★★ | 11 | 0 |
| Rio Rancho Center | 4.8 mi | ★★★★★ | 10 | 0 |
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