La Vida Llena
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 10501 Lagrima De Oro Ne, Albuquerque, New Mexico 87111
- CMS Provider Number
- 325035
- Inspections on file
- 18
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at La Vida Llena during CMS and state inspections, most recent first.
Surveyors found multiple expired food items stored in both the main kitchen and the serving kitchen, including drinks, salsa, boiled eggs, cheese slices, spinach, and yogurt, all past their labeled use-by or expiration dates. The Dietary Manager confirmed the items were expired and acknowledged that staff are expected to monitor dates and discard outdated foods, noting that residents are at risk of foodborne illness if served expired items.
The facility failed to prevent avoidable accidents for two residents by not following established transfer and fall-prevention measures. One resident with dementia and Alzheimer’s disease, care planned for a one-person stand-and-pivot transfer with a gait belt, was instead transferred with a mechanical Sara lift, resulting in a witnessed fall with head injury and a skin tear. Another resident with aphasia, dementia, and Alzheimer’s disease had a history of multiple falls and was care planned for fall mats on both sides of the bed, but required fall risk assessments were not completed for several months, and the fall mat was observed stored against the wall while the resident was in bed. The DON and staff acknowledged that transfer requirements and fall assessment protocols were not followed as expected.
Surveyors found that staff failed to protect resident PHI on the 600-unit. A paper listing resident names and vital signs was left unattended and visible on a medication cart in a common area, and the cart’s computer screen was left on and unattended in a hallway, displaying full resident names, prescribed medications, and allergies. On another occasion, a daily unit census with resident names and room numbers was left uncovered and visible on the same cart. An LPN and an RN each confirmed that the exposed information was PHI and acknowledged it was visible to anyone passing by, and the DON stated the expectation is that PHI should not be open for anyone to view.
A cognitively intact resident with Type 1 DM, anxiety, and depression was placed on a Wanderguard and restricted from leaving the unit despite facility policies stating that restraining ambulatory residents simply to prevent wandering is unacceptable and that elopement applies to those with impaired cognition. The resident’s MDS showed a BIMS of 15 with no wandering behaviors, a MOCA score of 28/30, and a neuropsychological evaluation with negative dementia screening, yet the care plan labeled the resident as an elopement risk and called for a security bracelet. The Medical Safety Device Assessment for the Wanderguard was incomplete, and there was no documented evidence of unsafe wandering, elopement attempts, or implementation of less restrictive interventions before applying the device. The resident reported feeling isolated, depressed, and like a “caged animal” due to the Wanderguard and inability to attend preferred on-campus activities, while multiple staff acknowledged the resident’s emotional distress and conflictingly described the rationale for the device as related to diabetes management and perceived safety concerns.
The facility did not complete required significant change in condition MDS assessments for two residents who began hospice services. One resident with multiple conditions, including dementia and Alzheimer’s disease, was documented as starting hospice, yet a subsequent quarterly MDS did not reflect hospice services. Another resident with dementia, heart disease, NSTEMI, peripheral vascular disease, and hyperlipidemia started hospice, but no significant change MDS was completed afterward. The MDSC acknowledged that a significant change MDS is required when a resident begins hospice and confirmed it was not done for these two residents.
Surveyors found multiple failures in medication security and storage on one unit, including unlocked and unattended medication carts in resident areas containing scheduled oral medications, eye drops, inhalers, and injectables, as well as a loose, unidentified pill in a cart drawer and expired viral transport testing swabs stored in the medication room. Nursing staff, including an RN, an LPN, and the DON, acknowledged that carts are expected to be locked when unattended, free of loose medications, and that expired supplies should not be kept in medication storage areas.
A resident with multiple cardiovascular conditions was prescribed Clopidogrel, an antiplatelet, as documented in physician orders and the MDS, but the care plan incorrectly identified the resident as receiving anticoagulant therapy and at risk from blood-thinning medications. During observation, the resident had bruising on both hands and reported being on an anticoagulant, and the DON later confirmed that the medical record did not show an anticoagulant order and that the resident had been care planned for the wrong type of medication.
Surveyors identified that the facility did not meet professional standards when one resident receiving hospice services lacked an active physician order for hospice despite documentation of hospice care in the record, and another resident with DM2 did not receive the ordered 1,000 mg dose of Metformin when an RN administered only 500 mg. The DON confirmed that a physician order is required for hospice admission and that nursing staff must follow physician orders and administer correct medication doses.
A resident with MS and identified nutritional risk, including weight loss and increased needs related to wound care, had physician orders for a regular diet, Prostat supplement, and monthly weights for routine monitoring. Weight records showed only a few documented weights over several months, with no entries after early July, and a later nutritional evaluation noted a 3% weight loss compared to a prior weight. The MDS assessment lacked a current documented weight, and the care plan called for weighing per physician orders. The DON confirmed that the last recorded weight was months earlier, that monthly weights should have been obtained or refusals documented, and that the resident’s weights were not being consistently monitored.
A resident with Type 1 DM on long-term insulin therapy had duplicate bedtime orders for Insulin Glargine-yfgn, each for 15 units, active over several days. Due to these unresolved duplicate orders and failure to accurately follow the facility’s medication administration policy, the resident was given 17 units instead of 15 units of long-acting insulin, resulting in multiple days of low blood sugars before the error was identified by the physician. The DON later confirmed that a medication error occurred and that the resident had received duplicate insulin orders and incorrect dosing.
An LPN failed to sanitize blood pressure cuffs after using them on a resident who was on Enhanced Barrier Precautions and then proceeded to document medication administration on a computer at the medication cart without disinfecting the equipment. In a follow-up interview, the LPN admitted forgetting to clean the cuffs and acknowledged that facility policy requires cleaning the equipment before leaving the resident’s room. This lapse in infection control was identified by surveyors as likely to result in transmission of infectious agents between residents and staff.
A resident with severe cognitive impairment was exploited by a sales consultant who accessed her financial information, purchased her home below market value, and fraudulently obtained a refund for her hearing aids after her death by misrepresenting himself as her grandson. The facility lacked controls over staff and visitor access, did not maintain visitor logs, and failed to ensure concerns about the consultant's actions were reported or investigated, resulting in misappropriation of the resident's property.
The facility failed to maintain sanitary food storage conditions, with raw salmon improperly stored above salsa, risking cross-contamination. Expired salad dressings and an unsealed bottle of liquid smoke were found in dry storage. The Director of Dining Services and kitchen staff acknowledged these practices were against protocol.
A resident's oxygen nasal cannula was observed dragging on the floor as she moved in her wheelchair, violating infection control protocols. The resident, who required continuous oxygen for hypoxia, was unaware of the issue until informed. The facility's Infection Preventionist RN acknowledged the risk of contamination from the floor.
Expired Food Items Stored and Available for Use in Facility Kitchens
Penalty
Summary
Surveyors identified a deficiency in food storage and service sanitation when expired food items were found in both the main kitchen and the serving kitchen. During an initial tour of the main kitchen, a small refrigerator contained two pink drinks in covered cups marked with a use-by date that had passed, and a large refrigerator contained one container of salsa, one container of boiled eggs, and one individual package of cheese slices, all labeled with use-by dates that had already expired. In a follow-up observation of the main kitchen, the large refrigerator was found to contain a box of fresh spinach with a use-by date that had passed. In the small serving kitchen refrigerator, surveyors observed one container of salsa and one medium-sized container of plain yogurt, both beyond their use-by or expiration dates. The Dietary Manager confirmed these foods were expired and acknowledged that kitchen staff, including himself, were expected to monitor use-by dates and dispose of expired items, and stated that residents are at risk of foodborne illnesses if they receive expired food items. This deficient practice was determined to have the potential to affect all 46 residents listed on the facility’s census at the time of the survey.
Failure to Follow Transfer Requirements and Fall-Prevention Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and appropriate fall prevention measures for two residents. One resident with dementia and Alzheimer’s disease, who was dependent on staff for most ADLs, was care planned and documented in the Kardex as requiring a one-person stand-and-pivot transfer with a gait belt. There was no documentation in the EMR indicating a need for a Sara lift or any other mechanical transfer device. Despite this, a CNA used a Sara lift to transfer the resident from bed to wheelchair, during which the resident experienced a witnessed fall, sustaining a head injury and a skin tear to the left wrist and requiring transfer to the ER. The DON confirmed that the fall occurred because the CNA used a Sara lift even though the resident did not require one, and both the CNA and DON stated that staff are expected to be familiar with each resident’s transfer requirements. The second resident, with aphasia, dementia, and Alzheimer’s disease, had a documented history of nine falls, including falls from bed and wheelchair related to leaning forward, confusion, balance problems, poor communication/comprehension, and unawareness of safety needs. The resident’s care plan included interventions such as placing a fall mat on both sides of the bed when the resident was in bed. However, review of the EHR showed that required fall risk assessments had not been completed since September 2024, despite the facility’s expectation that such assessments be done on admission, quarterly, and after each fall. During an observation, the resident was found lying in bed without the fall mat in place as care planned; instead, the mat was stored against the wall. The DON confirmed that the fall risk assessments were not completed as required and that the fall mat should have been present whenever the resident was in bed.
Failure to Safeguard Resident PHI on Medication Cart and Census Documents
Penalty
Summary
Surveyors identified a deficiency related to failure to safeguard residents' protected health information (PHI) on the 600-unit. During an observation of the unit medication cart located by the fireplace in the common room, a white piece of paper containing PHI, including resident names and vital signs, was left unattended and visible to anyone nearby. An LPN confirmed that the paper contained PHI and had been left visible on the cart. In a separate observation, the 600-unit medication cart was left unattended outside a resident room with PHI displayed on the computer screen, including full resident names, prescribed medications, and allergies, and an RN confirmed that this information was visible to anyone walking by and that best practice is to ensure PHI is not visible to everyone. Additional observations showed that the daily unit census, containing full resident names and room numbers, was left unattended and visible on the 600-unit medication cart. An LPN confirmed that this PHI was visible to anyone walking by and stated that such information should always be covered to protect resident PHI. In an interview, the DON stated that the expectation is for PHI to be protected and not open for anyone's ability to view. These observations and staff confirmations demonstrate that PHI for residents on the 600-unit was repeatedly left exposed in common and hallway areas where unauthorized individuals could access it.
Unnecessary Wanderguard Use and Movement Restrictions on Cognitively Intact Resident
Penalty
Summary
The deficiency involves the use of a Wanderguard (elopement-prevention device) on a cognitively intact resident without adequate assessment, documentation, or evidence of unsafe wandering or elopement behaviors. Facility policies on elopement and wandering management state that elopement applies to residents with impaired cognition and/or poor safety awareness, and that residents will be assessed for elopement risk upon admission and at set intervals. The Wanderguard policy specifies that restraining an ambulatory resident simply to prevent wandering is unacceptable and that residents should feel allowed their freedom while under close observation. Despite these policies, the resident was placed on a Wanderguard, and the Medical Safety Device Assessment used for Wanderguard placement was documented as incomplete. The resident’s records showed an admission date with diagnoses including Type 1 diabetes mellitus, anxiety disorder, major depressive disorder, and an initial diagnosis of dementia that was later questioned. A speech therapy discharge summary documented a MOCA score of 28/30, indicating no severe cognitive impairment, and prior cognitive functioning without need for supervision. A neuropsychological evaluation reported that dementia screening was negative, and the facility’s medical director agreed with a diagnosis of neurocognitive disorder but disagreed with the dementia diagnosis. The admission MDS documented a BIMS score of 15, indicating intact cognition, and no wandering behaviors exhibited. The resident’s care plan, however, labeled the resident as an elopement risk/wanderer related to a history of attempts to leave the facility unattended, called for monitoring location every 15 minutes, and documented use of a security bracelet related to poor safety awareness and forgetfulness associated with Type 1 diabetes, but did not include documented evidence of unsafe wandering or elopement attempts. The resident repeatedly reported psychosocial distress related to the Wanderguard and movement restrictions. In complaint intake forms, the resident stated that the Wanderguard prevented leaving the unit to attend activities elsewhere on campus, caused feelings of isolation among residents with cognitive deficits, and contributed to depression and negative effects on mental health. The resident reported feeling like a “chained elephant in a cage” and expressed a desire for more rights and the ability to do enjoyable activities, including worship and socializing in the independent living area where the resident had previously lived. Staff interviews confirmed the resident’s emotional distress: the SSD and NP reported the resident cried, shook, and became upset about loss of independence and Wanderguard use, and an LPN stated the resident felt she was losing independence due to the device. Facility staff provided varying accounts regarding the rationale for the Wanderguard. The DON stated the resident was assessed as a moderate elopement risk and that the Wanderguard was placed after this assessment, citing concerns about diabetic management, missed insulin doses, and inconsistent blood sugar monitoring, including an episode of blood sugar at 400 when the resident left without appropriate checks. The MD stated the Wanderguard was applied after two less restrictive safety measures failed, describing periods of clarity followed by behavioral escalation, removal of the device, attempts to leave to see the resident’s husband and dog, and aggressive behaviors, and characterized some unsupervised departures as elopement. However, the SSD stated she was unaware of any elopement attempts and confirmed the resident’s BIMS score of 15 with no cognitive concerns. The spouse reported that the resident was capable of independent activities in the area, believed the resident could leave the main building if staff were informed, and stated that after the resident left to attend to her dog and returned, the Wanderguard was placed. Despite the resident’s intact cognition and incomplete documentation of elopement risk and less restrictive interventions, the Wanderguard and associated movement restrictions remained in place, limiting the resident’s freedom of movement and contributing to psychosocial distress.
Failure to Complete Significant Change MDS Assessments for Residents Starting Hospice
Penalty
Summary
The facility failed to complete required significant change in condition MDS assessments when two residents began receiving hospice services. One resident with diagnoses including aphasia, dysphagia, dementia, Alzheimer’s disease, and pulmonary embolism was referred to hospice for dementia on 11/17/25, with nursing progress notes documenting the start of hospice services on 11/18/25. However, the resident’s quarterly MDS dated 12/02/25 indicated the resident was not receiving hospice services, despite hospice having already begun. Another resident with diagnoses including aphasia, dysphagia, dementia, heart disease, NSTEMI myocardial infarction, peripheral vascular disease, and hyperlipidemia was referred to hospice for a heart disease–related diagnosis on 08/25/25, with hospice admission records showing hospice services began the same day. Review of this resident’s MDS assessments showed that a significant change in condition MDS was not completed after hospice services were initiated. During an interview, the MDS Coordinator stated that a significant change in condition MDS should always be completed when a resident begins hospice services and confirmed that such assessments were not completed for these two residents.
Failure to Secure Medication Carts and Remove Expired Supplies
Penalty
Summary
Surveyors identified a deficiency related to the storage and security of medications and medical supplies on the 600 unit. During an observation on the unit, a medication cart was found unlocked and unattended outside a resident room, and the responsible RN acknowledged that he had left the cart in that condition, stating that medication carts should not be left unlocked and unattended. In a separate observation of the 600-unit medication storage room, surveyors found expired Universal Viral Transport testing swabs for Chlamydia, Mycoplasmas, and Ureaplasma in a drawer, with an expiration date of 05/14/25. The RN present confirmed the expiration date and stated that expired medical supplies and equipment should be discarded per policy. Further observations of the 600-unit medication cart revealed an oval light blue pill stamped with "SG" that was loose in a drawer, and the same RN confirmed the presence of the loose pill and stated that medication carts should be free of loose medications. In another observation of a common area, a medication cart was again found unlocked and unattended, containing residents' scheduled oral medications, eye drops, inhalers, and injectable medications. The LPN responsible for that cart confirmed it was her cart and stated that her expectation was to lock the cart when unattended, acknowledging that ingestion of non-prescribed medication by a resident could cause a bad drug interaction and illness. The DON later stated that medication carts should always be locked when nurses are away, kept clean and free of loose medications, and that there should be no expired supplies in medication rooms or carts.
Inaccurate Care Plan for Resident on Antiplatelet Therapy
Penalty
Summary
Facility staff failed to develop an accurate, comprehensive, person-centered care plan for one resident related to the resident’s medication regimen. The resident was admitted with multiple cardiovascular diagnoses, including coronary artery disease, paroxysmal atrial fibrillation, congestive heart failure, and peripheral vascular disease. Physician orders dated 12/16/25 showed the resident was prescribed Clopidogrel Bisulfate 75 mg by mouth in the morning for coronary artery disease, which is an antiplatelet medication. The resident’s MDS dated 05/27/25 documented that the resident was taking an antiplatelet medication and not an anticoagulant. Despite this, the resident’s care plan dated 05/28/25 stated the resident was on anticoagulant medication therapy and at risk from taking blood-thinning medications, inaccurately reflecting the type of medication actually prescribed and administered. During observation and interview on 12/15/25, the resident was noted to have bruising on both hands and reported being on an anticoagulant and bruising easily. In a subsequent interview on 12/19/25, the DON confirmed that the electronic medical record did not show an anticoagulant order, acknowledged that the resident had been care planned for an anticoagulant instead of an antiplatelet, and stated that anticoagulants and antiplatelets are significantly different types of medications.
Failure to Obtain Hospice Order and Follow Diabetic Medication Orders
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident receiving hospice services. One resident with diagnoses including aphasia, dysphagia, dementia, Alzheimer’s disease, and pulmonary embolism was admitted to the facility and later had a physician order dated 11/17/25 to be referred to hospice for dementia. Nursing progress notes documented that hospice services began on 11/18/25, and the resident’s care plan initiated on 11/11/25 indicated the resident was admitted to hospice for a terminal prognosis and multiple comorbidities. However, the quarterly MDS dated 11/20/25 indicated the resident was not receiving hospice services, and there was no active physician order for hospice care in the record, which the DON confirmed should have been present for any resident admitted under hospice care. The facility also failed to follow physician orders for a resident with Type 2 Diabetes Mellitus. The resident’s comprehensive care plan dated 10/21/24 documented an intervention to increase Metformin from 500 mg to 1,000 mg daily, and a physician order dated 12/16/25 specified Metformin 1,000 mg. During an observation on 12/17/25, an RN administered only one 500 mg tablet of Metformin instead of the ordered 1,000 mg dose. In a subsequent interview, the RN acknowledged not following the physician’s order when administering the medication, and the DON confirmed that nursing staff are expected to follow physician orders and administer the correct medication dose.
Failure to Follow Physician Orders for Monthly Weights and Monitor Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident by not following physician orders for monthly weights. The resident, who had multiple sclerosis and was admitted with this diagnosis, had a quarterly MDS dated 12/08/25 that lacked a documented weight, despite instructions to base the weight on the most recent measure in the last 30 days. Physician orders included a regular texture, thin liquid diet, an order dated 02/04/25 to weigh the resident every month for routine monitoring, and an order dated 08/26/25 for Prostat nutritional supplement twice daily for wound healing. The resident’s care plan, dated 08/26/25, identified potential nutrition risk due to inadequate oral intake, non-significant weight loss, and increased nutrition needs related to wound care, with interventions that included weighing per physician orders. Review of the electronic health record weight tracking from 03/01/25 through 12/22/25 showed documented weights on 03/25/25 and 04/01/25 of 125.4 lbs and on 07/01/25 of 120.8 lbs, with no documented weights after 07/01/25. A nutritional evaluation dated 10/25/25 documented a 3% weight loss (4.6 lbs) compared to the 04/01/25 weight. During an interview on 12/22/25, the DON confirmed that the last documented weight was in July 2025, acknowledged that the resident should have been weighed monthly per physician orders, and stated that if the resident refused weights, this should have been documented in the EHR. The DON stated the resident’s weights were not being consistently monitored and should have been.
Significant Insulin Dosing Error Due to Duplicate Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. The facility’s own Medication Administration Assistance Policy, dated 04/2017, requires staff to check the medication order for proper route, dose, time, strength, frequency, and type, and to notify the physician immediately of problems with medications. The resident, who had Type I diabetes mellitus with hyperglycemia, long-term insulin use, and unspecified cognitive symptoms, was admitted on a specified date and had physician orders for Insulin Glargine-yfgn 15 units at bedtime for diabetes. Physician orders dated over two consecutive days both directed administration of 15 units of Insulin Glargine-yfgn at bedtime, creating duplicate orders for the same long-acting insulin. Record review of the Medication Error Incident Report showed that the resident received the wrong dose of insulin when 17 units of long-acting insulin were administered instead of the ordered 15 units. The incorrect order and dosing error were not identified by the physician until several days later, during which time the resident experienced low blood sugars for multiple days after the additional administration. The Medication Administration Record confirmed that both insulin orders remained active until they were discontinued on the same later date. During an interview, the DON acknowledged that a medication error occurred and that the resident received a duplicate insulin order for several days and should not have, and stated that her expectation is that all residents receive correct medications and dosages per physician orders.
Failure to Sanitize Blood Pressure Equipment for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe, sanitary environment to prevent transmission of infectious agents when a nurse did not clean and sanitize vital sign equipment after use on a resident under Enhanced Barrier Precautions. During observation on 12/18/25 at 8:24 AM, an LPN took blood pressure measurements for Resident #39, who was on Enhanced Barrier Precautions, and then failed to sanitize the blood pressure cuffs before leaving the resident’s room. The LPN then proceeded to document medication administration on a facility computer located on top of the medication cart without having disinfected the equipment used on the resident. In a subsequent interview at 8:25 AM, the LPN confirmed that she forgot to clean the blood pressure cuffs after using them on Resident #39 and acknowledged that, per facility policy, the cuffs should have been cleaned prior to leaving the resident’s room. The LPN also confirmed that Resident #39 was on Enhanced Barrier Precautions at the time of the incident. The survey findings state that this deficient practice is likely to result in the transmission of infectious agents between residents and staff.
Failure to Protect Resident from Exploitation and Misappropriation of Property
Penalty
Summary
A facility failed to protect a resident from exploitation and misappropriation of property by a sales consultant employed at a sister facility within the same corporate campus. The sales consultant, who had access to the resident's personal and financial information through the Independent Living facility's intake process, fraudulently obtained a $1,569 refund for the resident's hearing aids after her death by misrepresenting himself as her grandson to an outside company. The refund was deposited into his personal account rather than the resident's estate. The sales consultant did not notify facility administration or seek direction regarding the handling of the resident's property, and only later sent a cashier's check to the resident's Power of Attorney for Finance, which was made out incorrectly. The resident in question had severe cognitive impairment, as evidenced by a BIMS score of 00 and diagnoses including metabolic encephalopathy, altered mental status, and dementia. She was admitted to the Skilled Nursing facility after a period in the Independent Living facility, and her medical records indicated ongoing confusion and vulnerability. The resident's Power of Attorney for Finance was not informed about the sale of the resident's house, which was purchased by the same sales consultant for less than market value, with significant closing fees deducted. The Power of Attorney expressed concerns that the resident was isolated from trusted advisors and did not fully understand the transactions she was involved in. Facility staff and visitors were able to move freely between the three facilities on campus without signing in, and there was no visitor log to track who entered or visited residents. Multiple staff members, including a social worker and an anonymous staff member, were aware of irregularities regarding the sales consultant's involvement with the resident's affairs but did not consistently report these concerns to administration or authorities. The Executive Director acknowledged awareness of the home purchase but did not provide investigation records, and the facility did not provide relevant records from the resident's time in the Independent Living facility, stating they were not relevant to her stay in the Skilled Nursing facility.
Improper Food Storage and Expired Items in Kitchen
Penalty
Summary
The facility failed to store and serve food under sanitary conditions, as observed during an inspection of the kitchen. Raw salmon was improperly stored in a zip-lock bag above small cups of salsa in the refrigerator, which could lead to cross-contamination. The Director of Dining Services acknowledged that this was against the facility's food storage protocols, which require staff to ensure food is stored correctly to prevent contamination. Additionally, during an observation of the dry storage area, four unopened and expired bottles of salad dressings were found mixed with unexpired ones, and a bottle of liquid smoke was discovered with a broken seal and without a lid. Kitchen Staff #1 confirmed that expired items should not be present in the storage area and should be discarded. The Director of Dining Services stated that staff are expected to check the dry storage area every two days to remove expired items and ensure all items are adequately sealed and labeled.
Infection Control Breach: Oxygen Cannula Dragging on Floor
Penalty
Summary
The facility failed to maintain proper infection prevention measures when a resident's oxygen nasal cannula dragged on the hallway floor. The resident, who had a physician's order for continuous oxygen therapy due to hypoxia, was observed propelling herself in a wheelchair toward an activity while her nasal cannula and oxygen line trailed behind her on the floor. During an interview, the resident expressed her discomfort upon realizing that the cannula she used in her nose had been in contact with the floor. The facility's Infection Preventionist Registered Nurse confirmed that oxygen tubing and nasal cannulas should not drag on the floor due to the risk of contamination from bacteria, viruses, and germs.
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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