La Vida Buena Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, New Mexico.
- Location
- 2301 Collins Drive, Las Vegas, New Mexico 87701
- CMS Provider Number
- 325065
- Inspections on file
- 23
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at La Vida Buena Healthcare during CMS and state inspections, most recent first.
A resident received multiple psychotropic medications, including Lorazepam for anxiety, Haldol for behavioral disturbances, and Seroquel for depression, without properly completed psychoactive medication consent forms signed prior to administration. Record review showed only one consent form in the EHR, covering Lorazepam on a single occasion, with no consents for other periods of Lorazepam use or for Haldol and Seroquel. In an interview, the DON confirmed that consent forms should have been completed before giving these medications but acknowledged this did not occur, placing residents at increased risk for side effects such as drowsiness, insomnia, fatigue, and sexual dysfunction.
A resident experienced a fall and was transferred to a hospital, but the resident’s daughter reported she was not informed by facility staff and only learned of the incident when the hospital called for treatment permission. The hospice DON stated hospice was not notified until after the resident returned from the ER, while an LPN reported notifying hospice later that morning and asserted that hospice, not the facility, is responsible for informing the family. The DON stated that facility practice is to notify the family, physician, and hospice for residents on hospice but could not confirm that such notifications occurred in this case.
A resident sustained a fall resulting in a 7.0 cm x 2.0 cm laceration to the right side of the forehead and was transported to a local hospital for treatment, with the resident’s daughter first being notified by the hospital requesting permission to treat. Facility documentation confirmed the fall with injury, and the Administrator acknowledged being aware of the incident and that any fall with injury should be reported to the state agency, but confirmed that no Facility Initiated Report or required follow‑up report was submitted.
A resident sustained a fall resulting in a large forehead laceration and was sent to a local hospital, with the family first learning of the event from hospital staff. The DON acknowledged that no investigation was conducted, the exact time and circumstances of the fall were unknown, and required change-of-condition documentation and reporting were missing. An LPN and an RN each reported hearing a CNA call out, then finding the resident on the floor bleeding, but neither conducted an investigation, and the RN did not document his observations, leading to incomplete and insufficient medical record documentation of the incident.
A resident’s quarterly MDS assessment was not completed by the required due date. Review of the EHR showed the assessment was overdue, and during interview the DON confirmed that the quarterly MDS had been due and was not completed as required. This issue was identified during a review of multiple residents’ assessment accuracy and completion.
A resident’s quarterly MDS assessment was not electronically transmitted within the required 14-day timeframe. Review of the MDS log showed the quarterly assessment with a specific ARD remained in Draft status in the facility’s software and had not been encoded or transmitted. In an interview, the DON confirmed the assessment was due, acknowledged it was not transmitted, and stated that all MDS assessments are expected to be transmitted timely.
A resident returned from a hospital stay and did not receive the required comprehensive head-to-toe assessment upon readmission. EHR review showed no complete assessment was documented, and the DON confirmed that the assessment, including a full skin check, was not performed despite facility expectations that all residents returning from the hospital be assessed on arrival. This failure was noted as likely to affect accurate calculation of the resident’s risk score for skin breakdown or falls.
A resident experienced increased pain and knee swelling after being moved in bed for wound care, during which a nurse heard a loud pop. The incident was not reported to the DON or medical provider, was not documented in the medical record, and was not reported to the State Agency as required.
The facility did not promptly notify providers and a guardian about a resident's fall with injury, delayed informing the wound care nurse about another resident's scalp staples after a fall, and failed to timely alert providers about a third resident's worsening pressure ulcers. These lapses in communication were confirmed by interviews with staff and documentation review.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish or implement a grievance policy or promptly resolve complaints.
The facility did not report allegations of abuse and neglect to the State Agency within the required two-hour timeframe for three residents. In each case, incidents involving potential neglect or inappropriate staff responses were either not recognized as reportable events or were reported several days late, as confirmed by the facility administrator during interviews.
The facility did not ensure that care and services provided met professional standards of quality, as observed through practices that did not align with established guidelines.
A resident who was cognitively intact and valued outdoor activities was unable to participate in outings or walks outside due to the facility's van being out of service for several months. Staff confirmed that no scheduled outings occurred during this time, and other residents also expressed frustration about the lack of activities. The facility did not provide alternative means for residents to engage in community integration or outdoor activities, despite these being identified as important in care assessments.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not implement adequate measures to prevent new ulcers from developing.
Two nurse aides worked for more than four months without proper certification or enrollment in a training program, as confirmed by staff interviews and record review.
A resident who was alert, oriented, and capable of making his own decisions was repeatedly prevented from leaving the facility to go for walks or shopping, despite expressing his wishes and not being deemed incompetent. Staff redirected him back into the facility without offering alternative solutions, citing concerns about his safety due to a history of seizures and falls. The lack of outings and refusal to allow the resident to leave as he wished led to frustration and confusion, demonstrating a failure to respect his right to dignity and self-determination.
A resident who wished to go outside and participate in community outings was not allowed to leave the facility independently due to medical concerns, but the care plan was not updated to reflect this restriction or the need for staff supervision. The DON confirmed the care plan did not document the requirement for accompaniment, resulting in the resident's needs and preferences not being properly addressed.
A resident prescribed an anticoagulant for heart disease experienced a fall resulting in significant bruising and a hematoma. The nurse involved in the incident was unaware of the resident's anticoagulant use, having not reviewed the care plan or medication list prior to the event. Interviews with facility staff confirmed that nursing staff are expected to be familiar with residents' medications, and the lack of awareness was identified as a deficiency.
A resident who required assistance with ADLs due to physical and cognitive impairments was not offered the scheduled number of baths/showers according to her care plan and preferences. Documentation and staff interviews confirmed that the resident received significantly fewer baths/showers than scheduled, and both the resident and staff reported dissatisfaction with the frequency of bathing provided.
A resident with multiple complex medical conditions was transferred to the ER and a higher-level care hospital for severe sepsis without the facility provider being notified prior to or immediately after the transfer. Documentation did not indicate the reason for the transfer or provider notification, and interviews with staff and the DON confirmed that required notification did not occur.
A resident with complex medical needs was transferred to the ER following a change in condition, but nursing staff failed to document the change, the reason for the transfer, or provider notification in the medical record. Interviews with RNs and the DON confirmed that this documentation was required but missing.
A resident with a history of brain injury and dementia, requiring two staff for transfers, fell and sustained a head injury when a CNA attempted to transfer him alone. The CNA left the resident to seek help, but the resident, agitated and unwilling to wait, attempted to transfer himself, resulting in a fall. The facility's staff confirmed that proper procedures, including the use of a Hoyer lift, were not followed.
A facility failed to thoroughly investigate and report an incident where a resident fell and accused a CNA of abuse. The resident sustained a significant injury, and the facility's follow-up report lacked details on the abuse allegations and investigation outcome. Interviews revealed improper technique by the CNA, who did not use a Hoyer Lift or have assistance.
The facility failed to deliver meals on time to 84 residents, with grievances indicating meals were often late and cold. Observations showed breakfast served significantly later than scheduled, and interviews confirmed delays, with some residents left hungry. Staff acknowledged the issue, citing lack of help and attempts to find solutions.
The facility failed to maintain proper food storage and kitchen cleanliness. Observations revealed unlabeled and undated food items, including chicken patties, beef patties, apple sauce, sliced cheese, and corn tortillas, improperly stored. The kitchen area under the sink was also found dirty. The Dietary Manager confirmed these deficiencies, acknowledging the need for proper labeling, dating, and daily cleaning.
During a COVID-19 outbreak affecting 15 residents, staff failed to properly dispose of PPE and did not exchange masks after contact with contagious residents. Used PPE was discarded in regular trash instead of biohazard bags, and staff reused masks due to insufficient supply.
A resident with contractures and dementia developed a pressure sore on the coccyx, which was not consistently assessed or documented by the facility. Despite the presence of tunneling and a foul odor, weekly wound reports were missing or incomplete, leading to a deficiency in the necessary treatment and services to promote healing.
A resident with multiple health conditions experienced a worsening pressure ulcer due to the facility's failure to implement timely interventions and accurately document the wound's progression. Despite being at risk for skin breakdown, the resident's wound was not properly managed, leading to exposure of bone and infection. Delays in notifying the provider and securing a wound clinic appointment contributed to the deficiency.
The facility was found to have insufficient support staff to effectively manage food and nutrition services, potentially leading to unmet dietary needs, improper food storage, and longer meal service wait times for all 80 residents.
The facility failed to deliver meals on time for all 80 residents, with scheduled meal times not being adhered to. Observations and interviews revealed that lunch was served late, causing frustration among residents. An LPN attributed the delays to the absence of a Dietary Manager, and a Registered Dietitian confirmed the issue, stating efforts were being made to address it.
The facility failed to maintain professional standards in food service safety, with unlabeled and improperly stored food items, and a dirty kitchen environment. Observations revealed unlabeled potatoes, onions, and apples, as well as refrigerated items left out after delivery. The kitchen was found to be dirty, with grime on surfaces and a sticky freezer floor. These issues were confirmed by staff, who cited staffing shortages as a contributing factor.
A facility failed to honor a resident's preference to wake up at 9:00 am, instead waking them at 6:00 am. This was confirmed through interviews with the resident, the Administrator, a CNA, and the DON, despite the facility's policy to accommodate resident preferences.
The facility did not provide a homelike environment for 17 residents in the small dining room, as staff served meals on trays and left them for residents to eat from. Observations showed residents eating with plates, utensils, and cups still on trays. Interviews with the DON, ADM, and RDO indicated that this was a common practice, though it was acknowledged as not homelike. The DON and ADM were unsure of the reason for this practice, and the RDO preferred tray removal but did not confirm its impact on the environment.
A facility failed to complete a Minimum Data Set (MDS) assessment for a resident after a significant change in condition, specifically the discontinuation of hospice services. The MDS Coordinator confirmed that the assessment was not completed as required.
The facility failed to complete baseline care plans within 48 hours for three new residents, missing critical sections in Nursing, Social, Rehabilitative, and Nutritional Services. The DON confirmed the omissions, highlighting a lapse in meeting the expected care planning standards.
The facility failed to develop comprehensive care plans for three residents, leading to omissions in care plans for oxygen use, nutritional supplements, and treatment for skin tears. The DON confirmed these omissions during interviews.
The facility failed to provide scheduled showers for two residents, one with skin breakdown risk and another with cognitive impairments. Records showed inadequate documentation and adherence to shower schedules, confirmed by staff and resident interviews. The DON acknowledged the failure to provide necessary care.
The facility failed to ensure resident safety during transfers and fall prevention. Two residents were transferred using a Hoyer lift by a single CNA, contrary to the policy requiring two staff members. Additionally, a resident with a history of falls did not have anti-skid strips in their bathroom as required by their care plan, increasing the risk of falls. The DON confirmed these deficiencies.
A facility failed to conduct a monthly Drug Regimen Review for a resident, as required for unnecessary medications. The resident had a physician's order for duloxetine HCI, but documentation was missing from the Medication Regimen Review binder for several months. The DON confirmed that the documents were given to medical records but could not be located.
The facility failed to monitor psychotropic medication use for four residents, neglecting to attempt gradual dose reductions as recommended by a pharmacist and not completing consent forms prior to medication use. Three residents continued receiving their prescribed medications without dose reduction attempts, and one resident's consent forms were signed months after medication initiation. The DON and ADON acknowledged these oversights.
The facility failed to notify two residents when their personal fund balances exceeded the Medicaid cash asset limit, risking their eligibility. The Business Office Manager did not send additional notifications beyond a quarterly statement and failed to inform the Social Services Director, who was unaware of the situation.
A resident with COPD and other conditions was using oxygen therapy without a physician's order, as confirmed by staff interviews and observations. The lack of a physician's order for the oxygen concentrator and nasal cannula at the resident's bedside indicates a failure to meet professional standards of care.
A resident experienced unmanaged pain from hemorrhoids due to the facility's failure to provide treatment. Despite the resident's daughter requesting hemorrhoid cream, the facility did not supply it, leading the daughter to bring and apply cream from home. The resident's records lacked orders or documentation for hemorrhoid treatment, and staff interviews revealed a lack of awareness and communication about the resident's condition.
A resident with major depressive disorder and anxiety did not receive necessary behavioral health care due to the facility's failure to ensure effective communication and documentation. The resident was discharged from talk therapy and only received medication management, despite staff being aware of her depression. The Social Services Director did not send a referral for talk therapy, and the psychiatric service provider suggested a referral if the resident desired it.
The facility failed to properly store medications and dispose of expired supplies, potentially impacting resident health. Loose pills were found in a medication cart, and expired Sani Cloth wipes were discovered in the medication room. A CMA and an RN confirmed the deficiencies, noting that nursing staff and the pharmacy are responsible for managing these issues.
A resident was served beans despite her care plan and meal ticket specifying no beans. The resident expressed dissatisfaction with the limited meal choices and being served food she disliked. Staff interviews confirmed the oversight, acknowledging the resident's meal ticket indicated no beans.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of psychotropic medications. Record review showed multiple physician orders for Lorazepam, prescribed as needed every four hours for anxiety on several occasions, with each order later discontinued. Additional orders included Haldol 0.5 mg as needed for behavioral disturbances and Seroquel 25 mg twice daily for depression, both of which were also later discontinued. These medications were administered without corresponding, timely psychotropic medication consent forms signed by the resident or resident representative. Review of the resident’s Electronic Health Record revealed that a Psychoactive Medication Consent Form was completed only once, on 01/06/26, and only for Lorazepam. No other consent forms were found for the resident’s use of Seroquel, Haldol, or for the other periods of Lorazepam use. During an interview on 03/09/26 at 12:35 pm, the DON confirmed that psychoactive medication consent forms should have been completed prior to administering Lorazepam, Haldol, and Seroquel to this resident, but acknowledged that this did not occur. The report states that this deficient practice is likely to put residents at increased risk for undesirable side effects associated with these medications, including increased drowsiness, insomnia, fatigue, and sexual dysfunction.
Failure to Notify Family and Hospice After Resident Fall and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s family and hospice provider following a fall and transfer to the hospital. The resident’s daughter reported that she first learned of her mother’s fall and hospitalization when she received a call from the hospital requesting permission to treat her mother early in the morning, and that the facility had not contacted her about the fall or the transfer. She stated she would have liked to receive a call from the facility and felt as if the staff did not care, and she was not notified by the facility until after her mother returned from the hospital. The Hospice Director of Nursing stated that hospice had not been notified by the facility until after the resident returned from the emergency room, at which time the hospice nurse went to the facility to assess the resident. An LPN reported that hospice was notified later that morning after the fall and stated that once hospice is notified, hospice is responsible for notifying the family and that it is not the facility’s responsibility to notify the family. The DON stated that the facility should notify the family, the physician, and hospice if the resident is on hospice, but was unable to confirm that the family or hospice had been notified in this case.
Failure to Report Fall With Injury to State Survey Agency
Penalty
Summary
The facility failed to submit a Facility Initiated Report and a five‑day follow‑up report to the State Survey Agency after a resident sustained a fall with injury. Progress notes dated 02/28/26 at 5:23 p.m. documented that the resident experienced a fall that morning resulting in a 7.0 cm x 2.0 cm laceration to the right side of the forehead and was transported to a local hospital. During an interview, the resident’s daughter reported that she first learned of the incident when the hospital called her to obtain permission to treat her mother for the forehead laceration caused by a fall at the facility. In a separate interview, the Administrator acknowledged awareness of the incident and stated that any fall with injury should be reported to the state agency, confirming that this fall had not been reported as required. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents and being unable to assure residents’ safety.
Failure to Investigate and Document Resident Fall With Forehead Laceration
Penalty
Summary
The facility failed to thoroughly investigate a fall with injury involving one resident. Progress notes documented that the resident experienced a fall resulting in a 7.0 cm by 2.0 cm laceration to the right side of the forehead and was transported to a local hospital. The resident’s daughter reported that she was first informed of the incident by the hospital, which called her for permission to treat the forehead laceration caused by the fall at the facility. The DON stated that no investigation had been conducted for this fall, she could not confirm the exact time of the incident, and she was unable to locate documentation of a change in condition related to the fall with injury. The DON also could not confirm who witnessed the fall or how it occurred and acknowledged that the incident should have been investigated and reported to the State Agency but was not. Staff interviews further showed incomplete documentation and lack of investigative follow-up. The DON confirmed that the resident’s medical record was not complete and that notes were not thorough regarding what occurred during the incident. An LPN stated that she did not witness the fall but heard a loud noise and a CNA yelling that the resident was on the floor; she then observed the resident on the floor with a forehead laceration, arranged for transfer to the hospital, and wrote a progress note, but did not conduct an investigation. An RN reported that he also did not witness the fall, heard the CNA yell, found the resident on her side face down and bleeding, applied gauze, had the resident returned to her wheelchair and taken to her room, and that the oncoming nurse later sent the resident to the hospital. The RN acknowledged that he did not document the incident or his observations in the resident’s medical record.
Failure to Complete Quarterly MDS Assessment by Required Due Date
Penalty
Summary
The facility failed to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment was completed by the required due date. Record review of the resident’s electronic health record showed that a quarterly MDS assessment was due to be completed by 02/16/26. However, the assessment was not completed by that date. During an interview on 03/09/26 at 12:35 pm, the Director of Nursing (DON) confirmed that the quarterly MDS assessment had been due on 02/16/26 and acknowledged that it was not completed as required. This failure to complete the quarterly MDS assessment as scheduled was identified for 1 of 3 residents reviewed for assessment accuracy and completion, and the report states that this deficient practice is likely to result in residents not receiving care and treatment that meet their current needs.
Failure to Transmit Quarterly MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure timely electronic transmission of a federally mandated Minimum Data Set (MDS) quarterly assessment for one of three residents reviewed for MDS transmittal requirements. Record review showed that this resident’s MDS log listed a quarterly assessment with an Assessment Reference Date (ARD) of 02/16/26 that had not been transmitted. Further review of the quarterly assessment in the facility’s software revealed it remained in Draft status, indicating it was not completed, encoded, or transmitted. During an interview on 03/09/26 at 12:35 p.m., the DON confirmed that the quarterly MDS assessment was due on 02/16/26, acknowledged that it had not been transmitted electronically, and stated that all MDS assessments should be transmitted within the required 14-day timeframe, which did not occur in this case. This deficient practice was identified for 1 resident (R #1) out of 3 residents (R #1, #2, and #3) reviewed for compliance with MDS transmittal requirements, and the report notes that such a failure is likely to hinder the ability of regulatory bodies to oversee resident care and prevents the facility from accurately tracking clinical trends or declines in a resident’s condition over time.
Failure to Complete Comprehensive Readmission Assessment
Penalty
Summary
The facility failed to ensure a comprehensive and accurate assessment was completed for one resident upon readmission from an acute care hospital stay. Review of the electronic health record showed that no complete head-to-toe assessment was performed when Resident #1 returned from the hospital on the specified date. During an interview, the DON confirmed that Resident #1 was not assessed upon arrival from the hospital, acknowledging that facility practice requires all residents returning from the hospital to receive an assessment, including a head-to-toe skin assessment, upon arrival/admission. This failure to perform the required assessment upon readmission meant that the resident’s condition, including skin status, was not comprehensively evaluated as per facility expectations, and the report notes that this deficient practice is likely to not accurately calculate the resident’s risk score for skin breakdown or falls.
Failure to Report Possible Neglect Incident to State Agency
Penalty
Summary
The facility failed to report an incident of possible neglect involving a resident who experienced increased pain and knee swelling following care. The DON stated that she became aware of the resident's complaints and swelling several days after the incident, and upon investigation, learned that the nurse providing care had heard a loud pop while moving the resident in bed for wound care. The nurse did not report the incident to the DON or the medical provider, nor was the event documented in the resident's medical record. Additionally, there was no incident report completed, and the event was not reported to the State Agency as required. Review of facility self-reports confirmed that no incidents for this resident were reported during the relevant time period.
Failure to Notify Providers and Guardians of Resident Incidents and Changes in Condition
Penalty
Summary
The facility failed to notify appropriate parties, including providers and guardians, of significant changes in condition or incidents affecting three residents. In one case, a resident experienced a fall resulting in an injury above the right eye that required steri strips. The resident's guardian was not informed of the fall, as confirmed by both the guardian and facility staff, including an LPN and the Director of Nursing, who acknowledged the lack of notification. Another resident returned from the emergency room with scalp staples following a fall. The ER discharge instructions specified that the staples should be removed within 7 to 10 days. However, the facility's Registered Nurse Treatment Nurse (Wound Care Nurse) was not notified of the presence of the scalp staples until 24 days after the resident's return. Nursing progress notes indicated delays in obtaining physician orders for staple removal, and the wound care nurse, nurse practitioner, and DON all confirmed that timely notification did not occur. A third resident with a stage 4 pressure ulcer of the sacral region experienced a worsening of the wound, as documented in weekly wound progress forms and skin checks. Despite evidence of the wound increasing in size and the development of a new pressure ulcer, the facility's nurse practitioner and medical director were not notified of the decline until a significant delay had occurred. The nurse practitioner stated that earlier notification would have resulted in different wound care orders, and the medical director confirmed that immediate notification was expected when wounds worsen.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints.
Failure to Timely Report Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency (SA) within the required two-hour timeframe for three out of four residents reviewed for grievances. In one case, a resident reported that a nursing assistant left to get supplies during care and did not return, resulting in another staff member needing to assist. The facility did not initially identify this as an allegation of neglect and only recognized it several days later during a grievance audit, leading to a delayed report to the SA. In another instance, a resident reported that a nursing assistant responded to a call light but questioned the resident's use of the call light when the resident could not recall their need. This incident was also not reported to the SA within the required timeframe. Additionally, for a third resident, there was no abuse or neglect incident report present for an incident that occurred, and the administrator confirmed that this incident should have been reported to the SA as it involved allegations of neglect. Interviews with the administrator confirmed that these incidents were not reported in a timely manner as required by regulations, and the facility acknowledged the reporting failures during the survey.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff, or detailed events leading to the deficiency. No additional information about specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Provide Sufficient Activities and Outings Due to Inoperable Van
Penalty
Summary
The facility failed to provide a program of activities sufficient to meet each resident's capabilities, interests, and needs, as evidenced by the lack of scheduled outings and opportunities for residents to go outside or participate in community integration. One resident, who was cognitively intact with a BIMS score of 15, expressed frustration at not being able to leave the facility for walks or to go to the store, despite his care plan indicating the importance of outdoor activities. The resident was told he could not leave the facility without staff accompaniment, but staff availability was inconsistent, and outings had not occurred for several months due to the facility van being out of service. Interviews with the DON, Activities Assistant, and Activities Director confirmed that no outings had taken place for at least two to three months, and the posted activity calendars showed that all scheduled outings were canceled during this period. Other residents also reported being upset about the lack of outings. The Activities Director acknowledged that the van's inoperability had prevented any community outings or rides, and there was no alternative transportation provided. The deficiency was identified through record review and interviews, highlighting the facility's failure to meet residents' activity needs as documented in their assessments and care plans.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not take adequate measures to prevent the development of new ulcers. This deficiency indicates that necessary interventions to manage existing pressure ulcers and prevent further skin breakdown were not implemented as required.
Failure to Ensure Proper Training and Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than four months were properly trained and certified, as required. Record reviews showed that one nurse aide was hired as a Nurse Aide in Training and continued to work in that capacity for over 120 days before becoming a Certified Nursing Assistant (CNA). Another nurse aide was also employed as a Nurse Aide in Training for longer than 120 days. Interviews with the staff and the Director of Nursing confirmed that both individuals worked in the facility as nurse aides for more than four months without the appropriate certification or enrollment in a training program, contrary to regulatory requirements.
Failure to Honor Resident's Right to Dignity and Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination by not allowing him to leave the facility according to his preference. The resident, who was alert, oriented, and had a BIMS score of 15, expressed a desire to go for walks or shopping outside the facility. Despite being capable of making his own decisions and not being deemed incompetent, staff consistently redirected him back into the facility and did not offer alternative solutions or plans to accommodate his wishes. The resident reported frustration and confusion about why he was unable to leave, and his sister confirmed that he was capable of making his own decisions but was told he needed someone to sign him out. Interviews with staff revealed that the facility van had been out of service for months, affecting planned outings, and that staff were concerned for the resident's safety due to his history of seizures and falls. The DON and Activities Assistant both stated that the resident could not sign himself out and go alone, and staff would intervene if he attempted to leave. The resident was not provided with outings or alternative options, and his requests to leave were met with redirection rather than support or accommodation, resulting in a lack of respect for his autonomy and dignity.
Failure to Revise Care Plan for Resident's Supervision Needs
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was not permitted to leave the facility independently. The resident expressed a desire to be integrated back into the community and reported frustration at not being able to exercise his rights to go outside for walks or to the store without accompaniment. The activity assessment indicated that going outside for fresh air was very important to the resident. However, the care plan only included an intervention to encourage the resident to inform staff when he wanted to go out to purchase items, without addressing the new restriction that he could not leave the facility alone. The Director of Nursing confirmed that the resident was not considered safe to leave the facility on his own due to medical issues affecting his decision-making, but also stated that the resident had not been deemed incompetent. The care plan did not reflect the requirement for staff supervision when the resident left the facility, nor did it document the restriction on independent outings. The lack of care plan revision meant that the resident's current needs and restrictions were not accurately addressed in his care documentation.
Nursing Staff Unaware of Anticoagulant Use During Fall Incident
Penalty
Summary
Nursing staff failed to demonstrate competency in being aware of a resident's anticoagulant medication use, which was necessary for proper monitoring and care. A resident with heart disease was prescribed Xarelto, an anticoagulant, and the care plan required staff to monitor for complications and review medications for adverse interactions. Despite these requirements, a registered nurse involved in a fall incident with the resident was unaware that the resident was taking an anticoagulant. The nurse had not read the resident's care plan and only became aware of the medication after the fall occurred. Following the fall, the resident developed significant bruising and a hematoma on the face, which worsened over time. The nurse, as well as other facility staff interviewed, confirmed that nursing staff are expected to be familiar with residents' medications and care plans. The lack of awareness regarding the resident's anticoagulant use was confirmed through interviews with the nurse, nurse practitioner, registered nurse consultant, and medical director, all of whom stated that the nurse should have known about the medication prior to the incident.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring a resident's preference for the frequency of baths/showers. The resident, who required assistance with activities of daily living due to physical and cognitive impairments, was scheduled to receive baths/showers three times per week. However, documentation from both the electronic health record and shower sheets indicated that the resident was only offered or given a bath/shower on a few occasions out of the scheduled opportunities over a period of more than a month. Specifically, during March, the resident was offered three to four baths/showers out of thirteen scheduled opportunities, and in early April, only one out of three opportunities was offered. Interviews with the resident, staff, and the Ombudsman confirmed that the resident expressed dissatisfaction with the infrequency of baths/showers, reporting feeling dirty and not receiving enough personal hygiene care. Staff members, including nursing aides and LPNs, acknowledged the resident's complaints and confirmed that the resident was not being offered the scheduled number of baths/showers. The Director of Nursing also confirmed that the resident was not offered enough baths per week, as required by her care plan and preferences.
Failure to Notify Provider of Resident Change in Condition Prior to ER Transfer
Penalty
Summary
Facility staff failed to notify the resident's provider when there was a significant change in condition for a resident with complex medical needs, including a recent digestive system surgery, peritoneal abscess, malignant carcinoid tumor, and a colostomy. The resident was transferred to the emergency room (ER) and subsequently to a higher-level care hospital due to hypotension and altered mental status related to severe sepsis. Documentation in the electronic health record did not show that the provider was contacted prior to the resident being sent to the ER, nor was there documentation explaining the reason for the transfer or who authorized it. Interviews with facility staff, including an RN, LPN, DON, and the nurse practitioner, confirmed that the provider was not notified as required. The resident's family member also reported that the resident appeared unwell days prior to the transfer and that staff were made aware of the resident's declining condition. Facility policy and staff statements indicated that the provider should have been notified either before or immediately after the resident was sent to the ER, but this did not occur.
Failure to Document Change in Condition and ER Transfer
Penalty
Summary
Facility staff failed to ensure that medical records were updated and accurate for a resident who experienced a significant change in condition. The resident, who had a history of surgical aftercare, peritoneal abscess, malignant carcinoid tumor, and a colostomy, was discharged to the emergency room due to a change in condition. However, the facility's electronic health record did not contain documentation of the change in condition, the reason for the transfer to the ER, or evidence that the facility's provider was notified of the transfer. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires documentation of any change in condition, notification of the provider, and the reason for sending a resident to the ER. Despite these expectations, there was no documentation in the resident's record regarding the change in condition, provider notification, or the rationale for the ER transfer, as confirmed by the DON.
Failure to Follow Safe Transfer Procedures Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice, specifically regarding safe transfer procedures. The resident, who had a history of traumatic brain injury and dementia, required assistance from two staff members for transfers due to cognitive impairment and a risk of falls. Despite this requirement being clearly documented in the resident's care plan, a Certified Nurse Assistant (CNA) attempted to transfer the resident alone, which led to the resident falling and sustaining a head injury. The incident occurred when the CNA responded to the resident's call light and assisted the resident to bed. The CNA recognized the need for additional help to transfer the resident back to his chair but left the room to seek assistance. During this time, the resident, who was agitated and unwilling to wait, attempted to transfer himself and fell, resulting in a laceration and hematoma. The Licensed Practical Nurse (LPN) and the facility's Administrator and Director of Nursing confirmed that the CNA did not follow the proper procedure, which required the use of a Hoyer lift and assistance from another staff member.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation and report timely to the State Survey Agency regarding an incident involving a resident who fell while being assisted to bed by a Certified Nurses Aide (CNA). The resident sustained a large cut above his left eye and was found in a puddle of blood. During the incident, the resident accused the CNA of hitting him. The incident was reported to the New Mexico Health Care Authority, but the follow-up report lacked details about the abuse allegations and the outcome of the investigation. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM) revealed that the facility had conducted interviews and collected statements from staff, concluding that the injury resulted from improper technique by the CNA, who failed to use a Hoyer Lift and did not have a second person to assist. Despite these findings, the follow-up report was incomplete and did not include necessary information about the abuse allegations or the investigation's outcome.
Consistent Meal Delivery Delays in LTC Facility
Penalty
Summary
The facility failed to deliver meals consistently and timely to 84 residents, as observed and reported in the facility's grievance records. Multiple grievances were filed by residents and family members, indicating that meals were often late and sometimes cold, with breakfast, lunch, and dinner being served significantly later than the scheduled times. Observations on a specific day showed breakfast trays being served between 8:45 am and 9:35 am, despite the scheduled time being 8:00 am. Interviews with residents and family members confirmed the delays, with reports of meals being served close to the next meal time and instances where residents were left hungry or had to resort to eating snacks like donuts. Staff interviews revealed awareness of the issue, with the Kitchen Manager and Facility Administrator acknowledging the problem and attempting to find solutions. The Facility Cook cited a lack of help as a reason for the delays, and the Social Services Director confirmed receiving multiple complaints about late meals. The facility attempted a new approach by serving the dining room first and room trays second, but the problem persisted, as evidenced by the continued late delivery of meals to residents in their rooms.
Improper Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to store and serve food under sanitary conditions, as observed during a survey. Several food items, including frozen chicken patties, beef patties, apple sauce, sliced cheese, and corn tortillas, were found improperly stored. These items were either left outside the freezer, open to air, or stored in the refrigerator without proper labeling or dating. The Dietary Manager confirmed that these items were not labeled or dated as required and acknowledged that potentially hazardous foods should not be left open to air or sitting on the counter. Additionally, the facility's kitchen was not maintained in a clean condition. The area under the sink and around the drain was observed to be dirty, with particles of dirt and grime present. The Dietary Manager confirmed the unclean condition and stated that the area should be cleaned daily, but was unable to provide a date for the last cleaning. This lack of proper food storage and kitchen cleanliness could potentially affect all 83 residents in the facility.
Inadequate PPE Disposal and Mask Usage During COVID-19 Outbreak
Penalty
Summary
The facility experienced an outbreak of COVID-19, affecting 15 residents who tested positive and were placed on COVID precautions. During this outbreak, staff failed to properly dispose of used personal protective equipment (PPE). Certified Nurses Aides (CNAs) reported that used PPE, including masks, gloves, and gowns, were disposed of in regular trash containers outside the building, rather than being treated as biohazardous waste. The Infection Control Nurse (ICN) confirmed that the used PPE should have been placed in red bags marked as biohazardous and disposed of in designated biohazard trash cans within the facility. Additionally, staff did not exchange or dispose of protective masks after contact with each contagious resident. A CNA admitted to using the same mask throughout the day, even when entering rooms of COVID-positive residents. The ICN acknowledged that staff should have exchanged their masks before and after entering any COVID-positive resident room, but this was not possible due to an inadequate supply of PPE masks at the facility.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide consistent pressure ulcer care for a resident, leading to a deficiency in treatment and services necessary to promote healing and prevent new ulcers. The resident, who was admitted with multiple diagnoses including contractures and dementia, developed a pressure sore on the coccyx. The sore was initially noted as healing but later described as having a foul odor and tunneling. Despite these observations, the facility did not conduct consistent weekly wound assessments and measurements as required. The Director of Nursing confirmed that the wound care nurse was responsible for weekly assessments and reports, but there were gaps in documentation. Specifically, there were no wound reports for the weeks following the initial identification of the pressure sore, and the reports that were completed lacked comprehensive details, such as measurements of tunneling. This inconsistency in wound care documentation and assessment contributed to the deficiency identified by the surveyors.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident with a pressure ulcer, leading to the deterioration of the wound. The resident, who had multiple diagnoses including type 2 diabetes, dementia, and hypertension, was at risk for skin breakdown due to incontinence and decreased mobility. Despite these risks, the facility delayed implementing new interventions and treatments when the resident's wound began to deteriorate. The wound, initially identified as a stage 2 pressure injury, was not properly documented or reported to the provider when changes occurred, such as the development of a foul odor and tunneling. The facility's staff did not accurately document the presence and progression of the wound on skin checks and shower sheets, and there was a significant delay in notifying the provider of changes in the wound's condition. The resident's care plan included interventions such as daily and weekly skin checks and repositioning every two hours, but these measures were not effectively implemented or documented. The resident's wound worsened over time, eventually exposing bone and leading to osteomyelitis, a serious bone infection. Additionally, there was a delay in securing an appointment at the wound clinic, with the resident being seen 21 days after the order was made. Interviews with staff revealed a lack of communication and documentation regarding the wound's progression and the need for antibiotic therapy. The facility's Director of Nursing and Regional Nurse Coordinator acknowledged the failure to take timely action and the need for staff training on documenting wound progress and notifying providers of changes. The Family Nurse Practitioner also noted that she was not informed of the wound's deterioration, which could have prompted earlier intervention.
Insufficient Support Staff in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support staff to effectively carry out the functions of the food and nutrition services. This deficiency was identified through record review, interviews, and observations. The lack of adequate staffing is likely to result in residents' dietary needs not being met, improper storage of food (such as being open to air, not labeled, and dated), and longer wait times for meal service for all 80 residents residing at the facility.
Consistent Meal Delivery Delays
Penalty
Summary
The facility failed to deliver meals consistently and timely for all 80 residents, as observed and reported. Scheduled meal times were set for breakfast at 8:05 am, lunch at 12:05 pm, and dinner at 5:05 pm. However, on June 10, 2024, lunch was observed to be served late, with staff beginning to serve at 12:57 pm, despite the dining room being filled with residents by 12:24 pm. Interviews with an LPN and two residents confirmed that meals were often served late, causing frustration among residents. The LPN attributed the delays to the absence of a Dietary Manager. On June 11, 2024, breakfast and lunch were again served later than scheduled, as confirmed by a Registered Dietitian who acknowledged the issue and stated efforts were being made to address it.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. Several food items in the kitchen were not labeled or dated, including a tub of russet potatoes, a tub of onions, and a box of red apples. Additionally, refrigerated and frozen food items, such as strawberry shakes, scrambled egg mix, boneless pork butts, and garlic breadsticks, were left out on a prep table instead of being stored in a refrigerator or freezer after delivery. These findings were confirmed by a dietary aide, who acknowledged the oversight and attributed it to insufficient staffing during meal service. The kitchen's cleanliness was also found to be substandard, with dirt, grease, and grime observed on the floors, walls, and baseboards. A follow-up observation revealed a sticky freezer floor with brown liquid present. Both the dietary aide and the dietary manager confirmed these findings, citing staff shortages as a reason for the lack of proper cleaning. These deficiencies in food storage and kitchen cleanliness potentially affect all 80 residents in the facility, as they could lead to exposure to foodborne illnesses.
Failure to Honor Resident's Wake-Up Preference
Penalty
Summary
The facility failed to accommodate a resident's preference for their wake-up time, which is a violation of the resident's right to self-determination. The resident expressed a desire to get up at 9:00 am, as documented in their Admission Activity Assessment. However, staff consistently woke the resident at 6:00 am, disregarding the resident's stated preference. Interviews with the resident, the Administrator, a Certified Nursing Assistant (CNA), and the Director of Nursing confirmed that the staff did not honor the resident's choice, despite the facility's policy to accommodate such preferences.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for 17 residents who ate their meals in the small dining room. During an observation, it was noted that staff served the residents their lunch and left the food on the serving trays, with residents eating their meals with plates, utensils, and cups still on the trays. Interviews with the Director of Nursing (DON), Administrator (ADM), and Regional Director of Operations (RDO) revealed that serving meals on trays was a common practice, although it was acknowledged that this did not provide a homelike environment. The DON and ADM were unsure why this practice was followed, and the RDO expressed a preference for removing the trays but did not confirm whether the practice was homelike.
Failure to Complete MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition. The resident was admitted to the facility and later had hospice services discontinued as per physician orders. Despite this significant change, the staff did not complete the required MDS assessment. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the assessment should have been completed when the resident was discharged from hospice services.
Incomplete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create accurate baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure proper care upon their arrival. The baseline care plans for these residents were found to be incomplete, with missing sections in Nursing Services, Social Services, Rehabilitative Services, and Nutritional Services. This deficiency was identified during a record review and confirmed through interviews with the Director of Nursing (DON). For Resident #75, the baseline care plan was missing information in several key areas, including Nursing Services, Social Services, Rehabilitative Services, and Nutritional Services. Similarly, Resident #78's care plan lacked details in Nursing Services, Rehabilitative Services, and Nutritional Services. Resident #386's care plan was also incomplete, missing sections for Nursing Services, Rehabilitative Services, and Nutritional Services. The DON acknowledged these omissions and stated that it was her expectation for staff to complete the baseline care plans within the 48-hour timeframe.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which could result in staff being unaware of the residents' needs. Resident #58 was observed using a nasal cannula connected to an oxygen concentrator, as per a physician's order dated January 26, 2024, for continuous oxygen at 2 liters. However, her care plan, dated February 19, 2024, did not include this order. The Director of Nursing (DON) confirmed the omission during an interview, acknowledging that the care plan should have included the oxygen use. Resident #78 had a physician's order dated June 3, 2024, for a house shake twice daily, but his care plan, dated May 28, 2024, did not reflect this nutritional supplement. The DON confirmed the oversight. Similarly, Resident #386 had a physician's order dated June 4, 2024, for treatment of skin tears, but her care plan, dated June 11, 2024, did not include this treatment. The DON confirmed the omission, stating that the care plan should have included the treatment for skin tears.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the area of bathing and showering. Resident #15, who was at risk for skin breakdown due to bowel and bladder incontinence and decreased mobility, was scheduled to receive showers three times a week. However, records indicated that staff offered showers only three times out of 13 opportunities in May, and there was no documentation of showers or refusals in June. Interviews with the resident and staff confirmed that the resident did not receive the scheduled showers, and the Director of Nursing acknowledged the failure to provide the required care. Similarly, Resident #31, who had cognitive impairments and required assistance with ADLs, was scheduled for showers three times a week. The records showed that staff offered showers only three times out of 13 opportunities in May, with no documentation of showers or refusals in June. An observation and interview with the resident revealed signs of poor hygiene, and staff interviews confirmed the lack of adherence to the shower schedule. The Director of Nursing also confirmed that the resident did not receive the necessary assistance with showers.
Failure to Ensure Resident Safety During Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of residents during transfers using a Hoyer lift, as observed in the cases of two residents. According to the facility's policy, at least two staff members are required to assist with transfers using a mechanical lift. However, it was observed that a Certified Nursing Assistant (CNA) transferred one resident alone, despite the resident's need for extensive assistance due to spastic quadriplegic cerebral palsy and muscle weakness. Similarly, another CNA transferred a second resident alone, who had a history of muscle weakness and falls, without the required assistance. Both CNAs acknowledged their actions, and the Director of Nursing confirmed that the policy was not followed. Additionally, the facility did not implement necessary interventions to prevent falls for a resident with a history of unsteadiness and previous falls. The resident's care plan included the installation of anti-skid strips in the bathroom to prevent falls. However, during an observation, it was noted that these strips were absent. The Director of Nursing explained that the strips had been removed by maintenance staff to address a plumbing issue, but they had not been replaced, leaving the resident at risk of further falls.
Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to conduct a monthly Drug Regimen Review for one of the five residents reviewed for unnecessary medications. This deficiency was identified through a record review and interview process. Specifically, the facility did not have documentation available for the resident's drug regimen review from January 2024 through June 2024. The resident had a physician's order for duloxetine HCI, a medication used for depression, but the necessary documentation was missing from the facility's Medication Regimen Review binder. During an interview, the Director of Nursing stated that the documents were given to medical records, but they could not be located, confirming the absence of records for April and May 2024.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the use of psychotropic medications for four residents, leading to deficiencies in medication management. For three residents, the facility did not attempt a gradual dose reduction (GDR) for their psychotropic medications, despite recommendations from the pharmacist. Resident #3 continued to receive risperidone at 4 mg twice daily without any attempt at dose reduction, as recommended in the pharmacist's medication regimen review (MRR). Similarly, Resident #11 was administered fluoxetine at 60 mg daily without a GDR attempt, and Resident #19 continued to receive quetiapine fumarate at 25 mg daily despite a recommendation to discontinue the medication. The facility provider did not acknowledge or sign the MRRs for these residents, and the Director of Nursing (DON) was unaware of why these recommendations were not followed. Additionally, the facility failed to complete psychotropic medication consent forms prior to the use of such medications for Resident #29. The resident was prescribed aripiprazole and duloxetine, but the consent forms for these medications were only created and signed months after the medications were first ordered. The Assistant Director of Nursing (ADON) acknowledged that the consent forms should have been completed and signed when the orders were initially given. These deficiencies indicate a lack of adherence to protocols for psychotropic medication management, potentially leading to unnecessary medication administration or overmedication of residents.
Failure to Notify Residents of Excessive Fund Balances
Penalty
Summary
The facility failed to notify two residents when their personal fund balances were within or approaching $200.00 of the maximum amount allowed for Medicaid recipients. This oversight could potentially lead to the residents losing their Medicaid eligibility. A review of the facility's Resident Statement Landscape revealed that both residents had exceeded the eligible maximum amount. During an interview, the Business Office Manager (BOM) acknowledged that the residents' accounts were above the allowed cash asset limit and admitted that he did not send additional notifications to the families beyond a quarterly statement. He also failed to communicate with the Social Services Director (SSD) to assist the residents in spending down their accounts. The SSD confirmed that she was not informed about the residents' financial status, indicating a lack of communication within the facility.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to meet professional standards of care related to the use of oxygen for a resident diagnosed with chronic obstructive pulmonary disease (COPD), dysphagia, dementia, and hypertension. The resident was observed with an oxygen concentrator and nasal cannula at her bedside, yet there was no physician's order for oxygen therapy in her medical records. Interviews with staff, including a Certified Nurse Aide (CNA), the Assistant Director of Nursing (ADON), a Registered Nurse (RN), and the Director of Nursing (DON), confirmed the resident's use of oxygen therapy, particularly at night, without a corresponding physician's order. The CNA reported that the resident used a portable oxygen concentrator while in her wheelchair and was on 2 liters of oxygen per minute via nasal cannula, with checks every two hours to obtain her oxygen reading. Despite these observations and confirmations, the lack of a physician's order for oxygen therapy represents a deficiency in adhering to professional standards of care, potentially leading to adverse health outcomes for the resident.
Failure to Manage Resident's Pain Due to Hemorrhoids
Penalty
Summary
The facility failed to effectively manage pain for a resident who was experiencing discomfort due to hemorrhoids. The resident, along with her family, reported the pain and the need for hemorrhoid cream to the facility staff. Despite the daughter's request for hemorrhoid cream on a specific date, the facility did not provide any treatment, leading the daughter to bring cream from home and apply it herself. The resident's medical records did not contain any orders for hemorrhoid treatment or documentation of the resident's pain related to hemorrhoids. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition. A Certified Nurse Assistant (CNA) noticed blood when assisting the resident in the bathroom and reported it to a nurse, but could not recall which nurse was informed. A Registered Nurse (RN) stated she was unaware of the resident's hemorrhoids or pain. The Director of Nursing (DON) acknowledged that treatment should have been initiated when the hemorrhoids were identified, either upon admission or when reported by the resident's daughter.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder and anxiety. The resident was admitted with these diagnoses and was discharged from talk therapy, receiving only medication management. The care plan indicated the need for psychiatric services, but the resident was not offered talk therapy since the discharge. Interviews with staff, including CNAs and an RN, confirmed awareness of the resident's depression, yet no action was taken to address the need for talk therapy. The psychiatric service provider confirmed that the resident was only seen for medication management and suggested a referral for talk therapy if desired by the resident. The Social Services Director admitted to not sending a talk therapy referral and failing to document when residents were offered such services. This lack of communication and documentation resulted in the resident not receiving the necessary behavioral health care to address her depression and anxiety.
Improper Storage and Expired Supplies in Medication Room
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and medical supplies, which could negatively impact resident health. During an observation of the A-Wing facility medication cart, five loose pills were found at the bottom of drawer two. A Certified Medical Assistant (CMA) confirmed the presence of unidentified loose pills and stated that nursing staff is responsible for cleaning the carts and disposing of any loose or expired medications. Additionally, in the A-Wing medication room, one and a half boxes of expired Sani Cloth wipes were found, which expired in August 2023. A Registered Nurse (RN) acknowledged the expired wipes and stated that nursing staff, along with the pharmacy during monthly audits, are responsible for disposing of expired medications and supplies.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically by serving beans despite clear instructions not to do so. The resident, who was admitted to the facility on an unspecified date, had a care plan dated 05/03/24 that specified a regular diet with chopped meat and no beans. This preference was also noted on the resident's meal ticket. However, during a lunch observation, the resident was served pasta with red sauce, beans, and enchiladas, which included the beans she did not want. Interviews with the resident, a CNA, a dietary aide, and the dietary manager confirmed that the resident was served beans against her stated preferences, as indicated on her meal ticket.
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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