Fort Bayard Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Clara, New Mexico.
- Location
- 41 Fort Bayard Road, Santa Clara, New Mexico 88026
- CMS Provider Number
- 325120
- Inspections on file
- 17
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fort Bayard Medical Center during CMS and state inspections, most recent first.
A resident experienced multiple injuries of unknown origin, including bruises, scratches, and skin tears, and was unable to explain how these occurred. Although incident and investigation reports were completed, there was no documentation that these reports or their follow-up results were submitted to the state agency as required, and the state agency confirmed not receiving most of the necessary notifications.
A resident was given Lorazepam for anxiety and agitation without documented informed consent, as required for psychotropic medications. The DON confirmed that staff did not obtain written consent prior to starting the medication, and the resident's medical record lacked documentation of consent.
Two residents received psychotropic medications without proper medical justification: one was given Lorazepam for anxiety without a documented anxiety diagnosis, and another had an indefinite PRN Lorazepam order for restlessness, anxiety, or insomnia without provider rationale for use beyond 14 days, as confirmed by the DON.
A resident's medical record was not updated to include a newly documented diagnosis of moderate dementia with anxiety, despite staff expectations to update diagnoses lists when new conditions are identified. The omission was confirmed by the DON during an interview.
The facility failed to ensure residents were free from physical restraints unless medically necessary, as three residents had alarms attached to their wheelchairs or beds without proper assessments or physician orders. Staff confirmed the absence of necessary documentation, and an anonymous complaint suggested alarms were removed due to surveyor presence. The administrator acknowledged incomplete assessments for alarm use.
A facility failed to update a resident's care plan with current information, leading to discrepancies in the use of alarms. The care plan indicated the use of various alarms, but observations and staff interviews revealed that these alarms had been discontinued. The DON confirmed that the care plan had not been revised to reflect these changes.
The facility failed to post daily nurse staffing information, including the facility name, date, total number, and actual hours worked by RNs, LPNs, and CNAs, as well as the resident census per shift. Instead, staff names were written on whiteboards inside each unit. The facility also did not retain 18 months of staff posting records, as required.
The facility failed to maintain an effective infection prevention and control program, specifically in managing Legionella risk in the water system. The Infection Control RN could not provide necessary documentation, such as checklists for water flushes or facility maps, indicating a lack of oversight. This deficiency potentially affects all 105 residents, increasing the risk of infection spread.
The facility failed to maintain resident dignity by using disposable dishware for meals due to a broken dishwasher, causing dissatisfaction among residents. Additionally, a resident was subjected to a belt alarm without a physician's order, despite expressing discomfort and the ability to remove it, indicating a disregard for her self-determination.
The facility failed to maintain a homelike environment with comfortable sound levels, as loud alarms were disruptive to residents. Alarms, including bed, chair, and bathroom door alarms, were audible throughout the facility, causing distress and sleep disturbances. Despite residents' complaints, the noise issue remained unaddressed.
The facility improperly used alarms as physical restraints on residents without necessary assessments or physician orders. Alarms were placed on wheelchairs, beds, and bathroom doors for all new admissions, as confirmed by staff, without individualized assessments to determine their necessity. Medical records lacked documentation justifying the use of these alarms, indicating a systemic issue in the facility's approach.
A facility failed to assess a resident for the risk of entrapment from bed rails. The resident, in a comatose state, had bilateral half side rails without a physician's assessment or orders since admission. Nursing assessments were completed, but the reason for side rail use was marked as Not Applicable, and the MDS did not indicate bed rail use. Interviews revealed that the bed rails were not considered restraints and were not coded on the MDS, with no confirmation of assessments from PT or OT.
The facility failed to ensure that pharmacist recommendations were reviewed and implemented by physicians for two residents. One resident continued receiving omeprazole without documented evaluation, while another's recommendations to adjust ferrous sulfate and fluoxetine dosages were not reviewed. The DON confirmed the lack of documentation and was unsure of the review process.
The facility failed to obtain consent for psychotropic medications for two residents. One resident was prescribed Sertraline for depression without consent, despite having diagnoses of unspecified psychosis, dementia, and PTSD. Another resident received Quetiapine, Divalproex, and Sertraline for aggression and agitation without consent, with diagnoses of unspecified dementia, Alzheimer's, and severe vascular dementia with psychotic disturbance. The DON confirmed the lack of consent and the need for specific diagnoses for medication use.
A facility failed to provide a resident with the CMS-10055 ABN of Non-Coverage, which informs about potential non-coverage and financial liability for services. The form was not completed due to the absence of the Office Manager and her backup.
A facility failed to include a DNR order in a resident's baseline care plan within 48 hours of admission. This omission was confirmed by the DON and could result in the resident not receiving appropriate care, potentially placing them at risk of an adverse event.
The facility failed to update care plans for six residents, resulting in discrepancies between documented care and actual interventions. Alarms on wheelchairs, beds, and bathroom doors were not reflected in care plans, and one resident's care plan inaccurately included a bed alarm. These oversights indicate a lack of timely and accurate care plan revisions.
A resident with multiple medical conditions experienced severe weight loss, which was not addressed by the facility. The care plan indicated a risk of nutritional decline, but staff failed to follow protocols for monitoring and responding to weight changes. Communication and documentation lapses led to the nursing staff being unaware of the weight loss, and no interventions were implemented to address the resident's nutritional concerns.
A resident with diabetes was not administered all prescribed medications upon admission to a facility, leading to symptoms of high blood sugar and eventual hospitalization for diabetic ketoacidosis. The facility failed to monitor the resident's condition adequately, and staff did not report symptoms or check blood glucose levels, resulting in a serious health incident.
A resident experienced multiple falls and a serious injury due to inadequate assessment and supervision. Despite symptoms of fatigue and weakness, the resident was allowed to use a wheelchair without proper evaluation. The care plan indicated a fall risk, but staff failed to monitor changes in condition or document necessary assistance levels. Interviews revealed a lack of communication and understanding among staff, leading to the resident's falls and subsequent intracranial hemorrhage.
The facility failed to complete necessary discharge summaries for three residents at the time of their discharge. One resident's recapitulation form was delayed by five days and lacked a medication list, another had a medication list but no recapitulation or summary, and the third's form was completed a day late. The DON confirmed the inconsistencies and expected uniformity in discharge documentation.
The facility failed to ensure timely documentation of provider notes for three residents. A nurse practitioner and two medical doctors delayed signing progress notes by two to three days after visits. The Health Information Manager explained that providers dictate notes post-visit, which are then transferred to the facility's electronic system, but do not always include the visit time.
A facility failed to effectively plan a resident's discharge by not involving the Insurance Case Manager in securing Mi Via services, despite the resident's mother raising the issue. The ICM was not contacted for a discharge meeting, and there was no documentation of efforts to ensure services were in place, leading to a potentially unsafe transition.
Failure to Report Injuries of Unknown Origin and Investigation Results
Penalty
Summary
The facility failed to report all injuries of unknown origin and the results of related investigations to the State Survey Agency for one of three residents reviewed for falls. Specifically, a resident experienced multiple injuries of unknown origin, including a bruise on the chin, a large scratch from shoulder to hip, abrasions, and multiple skin tears on different dates. The resident was unable to state how the injuries occurred. Incident reports were completed for each event, but there was no documentation indicating that these reports or the follow-up investigation results were submitted to the state agency as required. During interviews, the facility's investigator stated that investigation reports and follow-up reports were completed and submitted via fax, but was unable to provide copies or fax confirmations due to computer issues. The state agency confirmed that it did not receive initial or follow-up reports for some of the injuries and only received an initial report for one incident, with no follow-up. There was no evidence in the facility's records to show that the required notifications and investigation results were sent to the state agency within the mandated timeframe.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed in advance about the administration of Lorazepam, including the reasons, risks, and benefits of the medication. Record review showed that the resident was admitted to the facility and had a physician's order for Lorazepam to be administered on specific days for anxiety and agitation. However, the medical record did not contain documentation of consent for the resident to take Lorazepam. During an interview, the DON confirmed that there was no written consent in the resident's file and acknowledged that staff are expected to obtain such consent prior to starting any psychotropic medication.
Failure to Ensure Medical Necessity and Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were only administered when medically necessary for two of three residents reviewed. For one resident with vascular dementia and psychotic disturbance, Lorazepam was prescribed and administered on multiple occasions for anxiety/agitation associated with shower days. However, a review of the medical record revealed that this resident did not have a documented diagnosis of anxiety, despite the medication being ordered for that purpose. The Director of Nursing (DON) confirmed that staff are expected to ensure an appropriate diagnosis is present prior to starting any medication, and acknowledged the absence of an anxiety diagnosis for this resident. For another resident with unspecified dementia and insomnia, Lorazepam was ordered to be given every four hours as needed (PRN) for restlessness, anxiety, or insomnia, with no specified end date. The medical record did not contain a rationale from the provider explaining why the PRN order was to continue for longer than 14 days, as required. The DON confirmed that the order was indefinite and that the necessary provider rationale for extended PRN use was missing from the record.
Incomplete and Inaccurate Medical Records for Resident Diagnoses
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one of three residents reviewed for unnecessary medications. Specifically, a resident was admitted with diagnoses including unspecified dementia and insomnia. However, a provider's progress note later documented a diagnosis of moderate dementia with anxiety, which was not added to the resident's official list of diagnoses. During an interview, the DON confirmed that staff are expected to update the diagnoses list when a new diagnosis is identified, but this was not done in this case.
Failure to Ensure Residents are Free from Unjustified Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless used to treat a specific medical condition, as identified through an assessment. This deficiency was observed in three residents who had alarms attached to their wheelchairs or beds without proper assessments or physician orders. For Resident #1, a seat belt alarm was attached to her wheelchair without a physician's order or any assessment indicating the need for such a device. Interviews with staff, including a CNA, RN, and the Director of Nursing, confirmed the absence of necessary documentation and consultation with the physician regarding the use of alarms. Similarly, Resident #2 had both a seat belt alarm and a bed alarm without any assessments to justify their use for a specific medical condition, despite a verbal order to continue their use. Resident #8 also had a seat belt alarm on her wheelchair without any documented assessment or physician consultation. The report further notes that staff were observed removing alarms from residents' rooms, and an anonymous complaint suggested that alarms were removed because surveyors were present. The facility administrator acknowledged that not all residents had been assessed for alarms by the time of the revisit, citing the time required to complete assessments.
Failure to Update Resident Care Plan with Current Information
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for a resident, leading to outdated information being used in their care. Specifically, the care plan for a resident, initiated on 10/30/23, indicated the use of a bathroom door alarm, bed alarm, and wheelchair alarm, which were to be checked for proper function every shift. However, observations and interviews revealed discrepancies. On 01/23/25, a CNA noted that the resident had a wheelchair alarm, despite stating earlier that alarms had been discontinued. Further clarification from an RN identified the alarm as a seat belt alarm, not a wheelchair alarm. The Director of Nursing confirmed that the care plan had not been updated to reflect the discontinuation of the alarms, indicating a failure to revise the care plan with the most current resident information.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information for all 105 residents. The deficiency was identified when the facility did not post essential staffing information, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, certified nurse aides, and the resident census per shift. Additionally, the facility did not retain 18 months of staff posting records, which is a regulatory requirement. During interviews and observations, it was revealed that the facility's practice was to write the names of staff working per shift on a whiteboard inside each unit, rather than posting the required information publicly. The Administrator confirmed that the facility does not post resident census numbers or staffing numbers. The Director of Nursing stated that the staffing schedule is posted outside her office, but it only shows staff names and their monthly schedule, without public notice of census numbers or staffing numbers for each shift. Furthermore, the facility could not demonstrate that they retained 18 months of posted staffing records.
Inadequate Legionella Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in managing the risk of Legionella and other opportunistic pathogens in the building's water system. The facility's Legionella Water Management Program policy outlines the need for a water management team and a detailed description of the water system, including areas where bacteria could grow. However, during the survey, it was found that the facility did not have a complete water management program in place. The Infection Control RN was unable to provide checklists for water flushes or facility maps and diagrams for the water management system, indicating a lack of proper documentation and oversight. This deficiency potentially affects all 105 residents in the facility, as the absence of a comprehensive water management program increases the risk of Legionella bacteria growth and transmission. The facility's failure to ensure the completion of water flushes and maintain necessary documentation could lead to the spread of infections among residents, compromising their health and safety.
Failure to Uphold Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to uphold the dignity of its residents by serving meals on disposable dishware and cutlery for an extended period. Observations revealed that residents across various dining areas were using disposable plates, cups, and utensils, which had been the practice for about a year due to a malfunctioning dishwasher. Interviews with residents indicated dissatisfaction with the use of disposable items, as it made them feel undervalued and like they were at a camp. Some residents expressed difficulty in cutting food with plastic utensils, which affected their independence. The Dietary Manager confirmed that the dishwasher had not been functioning properly since October 2023, leading to the continued use of disposable items. Additionally, the facility did not respect a resident's right to self-determination regarding the use of a belt alarm. A resident was observed with a lap belt alarm in her wheelchair, despite not having a physician's order for it. The resident expressed discomfort and embarrassment caused by the alarm, which she could remove herself. However, staff continued to reapply the belt, disregarding her preference. The resident's care plan indicated the use of a lap belt due to fall risk, but there was no specific order for the alarm, highlighting a lack of communication and respect for the resident's choices.
Facility Fails to Maintain Comfortable Sound Levels Due to Loud Alarms
Penalty
Summary
The facility failed to provide a homelike environment with comfortable sound levels for three residents. Observations and interviews revealed that loud alarms, including bed, chair, and bathroom door alarms, were audible throughout the facility, causing discomfort to residents. These alarms were initially installed for all new residents until assessed for fall risk. The noise from these alarms was reported to be disruptive, particularly at night, affecting residents' ability to sleep and causing distress. Staff confirmed the loudness of these alarms and acknowledged that they could be heard from significant distances within the facility. Specific incidents included residents expressing difficulty sleeping due to the noise from alarms in nearby rooms. One resident reported that the noise from a bathroom door alarm across the hall was particularly disruptive, occurring multiple times each night. Another resident mentioned that the bed and bathroom door alarms from a neighboring room were bothersome, and despite informing staff, no action was taken to address the noise. Additionally, a resident in the secured unit was observed covering his ears in response to the loud entry door alarm, which staff confirmed was a common reaction.
Improper Use of Alarms as Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless medically necessary. Observations, record reviews, and interviews revealed that five residents were subjected to alarms on their wheelchairs, beds, and bathroom doors without proper assessments or physician orders. Specifically, residents had alarms placed on their wheelchairs, beds, and bathroom doors as a standard practice upon admission, without individualized assessments to determine the necessity of such alarms. This practice was confirmed by both a CNA and a Unit Manager, who stated that all newly admitted residents received these alarms until assessed for fall risk. The medical records of the residents involved did not contain any physician orders or assessments justifying the use of these alarms. For instance, one resident had alarms on her wheelchair, bed, and bathroom door, but her medical record lacked any documentation supporting the need for these alarms. Similarly, other residents had alarms on their beds, wheelchairs, and bathroom doors without any corresponding physician orders or assessments. The Director of Nursing confirmed that alarms were used for all new admissions and evaluated later for necessity, indicating a systemic issue in the facility's approach to using alarms as a form of restraint without proper justification.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as R #35, was assessed for the risk of entrapment from bed rails. The resident was admitted to the facility on 10/21/14 and was observed on 08/07/24 to have bilateral half side rails on their bed. Despite being in a comatose state with no voluntary movement, the resident's medical records did not show any assessment by a physician for the use of these bed rails since admission, nor were there any current physician orders for them. Additionally, the MDS assessment did not indicate the use of bed rails, and the physical therapist had not been asked to assess the resident for bed rail use. The nursing bed rail assessments for the resident were completed on 03/09/24 and 06/24/24, but the reason for using the side rails was marked as Not Applicable. The head of the bed needed to be elevated for care, which increases the risk of entrapment, was marked as yes. Interviews with the DON and MDS Coordinator revealed that the bed rails were not considered restraints and were not coded on the MDS, although they were care planned for. There was no confirmation of bed rail assessments from PT or OT for the resident.
Failure to Review and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations were reviewed and implemented by the physician or that the physician provided a rationale for not following the recommendations for two residents. For Resident #31, the pharmacist recommended evaluating the continued need for omeprazole, a medication used to treat excess stomach acid. However, there was no documentation of the provider's response or signature on the pharmacist's note, and the resident continued to have an active order for omeprazole. The Director of Nursing (DON) confirmed the lack of documentation and was unsure of the provider's process for reviewing pharmacy recommendations. For Resident #50, the pharmacist recommended decreasing the dosage of ferrous sulfate, an iron supplement, due to normalized hemoglobin and hematocrit levels, and evaluating the dose of fluoxetine, an antidepressant. Both recommendations were not reviewed by the provider, and there was no documentation in the medical record regarding the prescriber's response. The DON confirmed the absence of documentation and expressed uncertainty about the provider's process for reviewing pharmacy recommendations. This deficiency could result in residents receiving unnecessary medications, potentially leading to adverse drug interactions or side effects.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medications unless necessary to treat a specific psychiatric diagnosis documented in the medical record. Additionally, the facility did not obtain consent from the residents' representatives for the use of these medications. Specifically, two residents were identified in this deficiency. One resident was prescribed Sertraline for depression without obtaining consent from their representative. The medical record review revealed that the resident had diagnoses of unspecified psychosis, dementia, and PTSD, but there was no documentation of consent for the medication. Another resident was prescribed multiple psychotropic medications, including Quetiapine and Divalproex for aggression and agitation, and Sertraline for agitation, without obtaining consent from their representative. The resident's diagnoses included unspecified dementia, Alzheimer's Disease, and severe vascular dementia with psychotic disturbance. The Director of Nursing confirmed that written consent was not obtained for these medications and acknowledged that aggression and agitation are not medical diagnoses, emphasizing the need for a specific diagnosed condition for the use of psychotropic medication.
Failure to Provide Beneficiary Notice of Non-Coverage
Penalty
Summary
The facility failed to inform a resident about changes in Medicare and/or Medicaid coverage for services, specifically by not providing the CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) of Non-Coverage. This form is crucial for informing residents about potential non-coverage and the option to continue services with the resident accepting financial liability. The deficiency was identified for one resident when the form was not completed or given prior to the end of services. The Office Manager explained that the notification was not completed due to her absence from work because of illness, along with the absence of her backup and supervisor.
Failure to Include DNR Order in Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for one of the residents reviewed. Specifically, the admission care plan for the resident did not include the physician's order for a Do Not Resuscitate (DNR) status, which is a legally recognized order indicating that the resident does not want to be resuscitated in the event of cardiac arrest or cessation of breathing. This omission was confirmed during an interview with the Director of Nursing (DON). The lack of inclusion of the DNR order in the care plan could likely result in the resident not receiving appropriate care, potentially placing them at risk of an adverse event or worsening of their condition after admission.
Care Plan Revision Failures for Alarm Interventions
Penalty
Summary
The facility failed to ensure timely and accurate revisions of care plans for six residents, leading to discrepancies between the care provided and the documented care plans. Specifically, the care plans for five residents did not include interventions for alarms on wheelchairs, beds, and bathroom doors, despite these alarms being present during observations. For instance, one resident's care plan, dated October 11, 2023, lacked documentation for wheelchair, bed, and bathroom door alarms, even though these alarms were observed in the resident's room. Additionally, another resident's care plan inaccurately documented the use of a bed alarm, which was confirmed to be unnecessary by both the Director of Nursing and the MDS coordinator. This resident's care plan was eventually updated to remove the bed alarm, but the initial oversight highlights the facility's failure to maintain current and accurate care plans. These deficiencies suggest that the care plans were not updated to reflect the most current resident conditions and interventions, potentially leading to staff being unaware of necessary changes in care.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as R #14, who experienced severe weight loss. R #14 had multiple medical conditions, including Tourette's Disorder, Paranoid Schizophrenia, Major Depressive Disorder, Hyperlipidemia, Dysphagia, and Chronic Kidney Disease. The care plan for R #14 indicated a risk of nutritional decline and specified that significant weight changes should be monitored and addressed. However, the facility did not follow protocols for identifying and responding to R #14's weight loss, which amounted to a 6.72% decrease in one month. The facility's staff, including the Unit Manager and Restorative Nursing Assistants (RNAs), failed to effectively communicate and document the resident's weight changes. Although RNAs were responsible for monitoring weights and notifying nursing staff of significant changes, there was no documentation to confirm that the nursing staff was informed of R #14's weight loss. The Unit Manager and RN #21 were unaware of the weight loss, and no changes were made to R #14's nutritional plan or physician's orders to address the issue. Additionally, R #14's weight loss was not discussed during the Risk Team meeting, which is intended to address potential risks for residents. The facility's Director of Nursing (DON) confirmed the weight loss and acknowledged that the expected protocol was not followed. The DON stated that significant weight changes should prompt a reweigh and notification to the nurse or nurse manager, followed by provider notification and order adjustments. However, these steps were not taken for R #14, and no interventions were implemented to address the resident's nutritional concerns. The lack of communication and documentation led to a failure in addressing the resident's severe weight loss, which was not recognized or managed by the facility.
Failure to Administer Diabetic Medications Leads to Hospitalization
Penalty
Summary
The facility failed to provide quality care for a resident with diabetes, leading to a serious health incident. Upon admission, the resident was not administered all prescribed diabetic medications, including Januvia, Glipizide, and Insulin glargine/Lantus, as per the hospital discharge summary. The facility only ordered Jardiance, and there was confusion regarding the resident's insulin requirement. This oversight was not clarified with the hospital, resulting in the resident not receiving necessary medications to manage her diabetes. The resident exhibited symptoms of high blood sugar, such as increased thirst, frequent urination, and fatigue, which were not adequately monitored or reported to a physician. Despite these symptoms, staff did not check the resident's blood glucose levels or administer the necessary medications. The resident's condition deteriorated over time, leading to an emergency room visit where she was diagnosed with diabetic ketoacidosis (DKA) and admitted to the hospital. Interviews with facility staff revealed a lack of communication and understanding of the resident's medical needs. The Assistant Unit Manager confirmed the confusion over the discharge paperwork and the failure to contact the hospital for clarification. Additionally, the Director of Nursing acknowledged that staff did not report the resident's symptoms or check her blood sugar levels, which they should have done according to the facility's diabetes policy.
Removal Plan
- Residents demonstrating signs and symptoms of hyperglycemia were transferred to the hospital.
- Residents with the diagnosis of diabetes mellitus will be audited to ensure orders are in place to reduce and/or prevent risk of severe adverse outcomes. Audits including blood sugar monitoring are included as part of the resident medication and/or treatment record.
- All applicable policies and procedures regarding admission assessment, physician orders and diabetic management were reviewed and revised when indicated by supporting professional references.
- The DON and Nursing Supervisors implemented a post admission checklist for all admissions. Admission Checklist is completed following completion of provider assessment and physician orders entry. Checklist includes review to ensure proper order transcription, correct medication administration, instruction for appropriate physician notification when residents demonstrate symptoms of hyperglycemia/hypoglycemia, review of necessary medical information and that the physician contact was properly documented. Checklist includes double checks by admitting nurse and unit manager.
- Admission checklist is completed following provider assessment at admission. Unit Manager/Nurse Supervisor will verify variances from documented treatment history to ensure orders are in agreement with treatment plan.
- The DON or designee re-educated licensed nurses on facility policies regarding admission procedures and diabetic management as well as medication reconciliation guidelines.
- Facility has secured additional providers to ensure that a provider is available in-house for all admissions. The provider will complete accurate review and completeness of admission assessments through reconciliation of all related admission documents.
- Medical providers have been trained on facility protocols regarding review of all related admission documents prior to or at admission. Providers shall document agreement with and/or changes with treatment history.
- Medical providers shall communicate with discharging entities to clarify any discrepancies in provided documentation.
- Direct care staff will be in-service regarding signs and symptoms of hypoglycemia and hyperglycemia and proper procedure to notify appropriate nursing staff.
- Direct care staff will be in-service on documenting all pertinent conversations in the electronic medical record.
- Licensed nursing staff will document communication with the provider through SBAR process. Evidence of notification will be included in the electronic health record.
Failure to Assess and Supervise Resident Leads to Falls and Injury
Penalty
Summary
The facility failed to adequately assess and supervise a resident, leading to multiple falls and a serious injury. The resident, identified as R #21, experienced fatigue, weakness, and dizziness, which were not thoroughly investigated by the staff. Despite these symptoms, the resident was allowed to use a unit wheelchair without a proper evaluation of her ability to do so safely. The care plan for R #21 indicated a risk for falls and required monitoring for changes in condition, but these measures were not effectively implemented. Physical therapy (PT) and occupational therapy (OT) evaluations were either incomplete or not conducted in a timely manner. PT recommended the use of a wheelchair without assessing the resident's ability to use it independently. The resident's care plan did not specify the level of assistance needed when using a wheelchair, and staff failed to document any changes in the resident's condition that could increase the risk of falls. This lack of assessment and documentation contributed to the resident's falls on multiple occasions. Interviews with staff revealed a lack of communication and understanding regarding the resident's needs and the use of the unit wheelchair. The unit manager and director of nursing confirmed that the resident was not properly assessed for wheelchair use, and the wheelchair was left with the resident without supervision. This oversight resulted in the resident sustaining an intracranial hemorrhage after a fall, highlighting the facility's failure to provide adequate supervision and prevent accidents.
Incomplete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that staff completed necessary discharge summaries for three residents at the time of their discharge. For the first resident, the Recapitulation of Stay form was not completed until five days after discharge, and it lacked the discharge medication list. The second resident's record contained a discharge medication list but was missing a recapitulation of the resident's stay and a discharge summary. For the third resident, the Recapitulation of Stay form was completed one day after discharge. During an interview, the Director of Nursing (DON) confirmed that the discharge summaries for these residents were not completed at the time of discharge. The DON acknowledged that each resident's discharge had different documents completed, but she expected all discharges to have consistent information. She also stated that staff should complete and sign the resident recapitulation of stay on the same day as the resident's discharge.
Deficiency in Timely Documentation of Provider Notes
Penalty
Summary
The facility failed to ensure that residents had written, signed, and dated progress notes from their healthcare providers at each visit. This deficiency was identified for three residents during a review of their medical records. For one resident, a nurse practitioner conducted a new patient encounter, but the note was not signed until two days later. Another resident's progress note by a medical doctor was not signed until three days after the visit. Similarly, a third resident's chronic care management note was signed three days post-visit. During an interview, the Health Information Manager explained that providers dictate their notes using software, which are then transferred to the facility's electronic system. However, the notes do not always include the time of the visit, as they are dictated after the resident is seen, and the provider must log in to sign the note once it appears in the electronic record.
Failure to Coordinate Discharge Planning with Insurance Case Manager
Penalty
Summary
The facility failed to develop an effective discharge plan for a resident, identified as R #1, who was transitioning from the facility to a private residence. The deficiency involved the lack of involvement of the resident's Insurance Case Manager (ICM) in securing services through Mi Via, a self-directed waiver program for individuals with intellectual and developmental disabilities. Despite the resident's mother raising the need for Mi Via services during an interdisciplinary team (IDT) meeting on November 9, 2023, prior to the resident's discharge on March 28, 2024, the facility did not take the necessary steps to ensure these services were in place. The facility's records revealed that the ICM was not contacted to attend a discharge meeting held on March 21, 2024, and there was no documentation explaining the absence of the ICM or any efforts to contact the Mi Via program. Interviews with the ICM and a Unit Manager confirmed these oversights, indicating that the facility did not ensure a safe and coordinated discharge process for the resident. This lack of coordination and documentation likely resulted in a complicated or unsafe transition for the resident from the facility to their home setting.
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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