Laguna Rainbow Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Casa Blanca, New Mexico.
- Location
- 240 Casa Blanca Road, Casa Blanca, New Mexico 87007
- CMS Provider Number
- 325214
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Laguna Rainbow Nursing Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary food and beverage practices, including an RN serving drinks to residents while gripping cups by the rim with bare hands and reporting no specific training on dining service, despite facility expectations that cups be held by the side to prevent cross contamination. A kitchen tour further revealed expired canned corn, a cracked container of frozen strawberries left open to air, an expired and unsealable gallon of milk, and large amounts of spilled dressing and barbecue sauce on the sides of bulk condiment containers in the refrigerator, contrary to the Dietary Manager’s stated expectations for weekly date checks, proper storage, and prompt cleanup of spills.
Surveyors found that PASARR Level 1 screenings were inaccurately completed for four residents with documented depression. In each case, the PASARR indicated no mental illness, while the face sheet and MDS showed a diagnosis of depression and, for several residents, ongoing antidepressant therapy. During interview, the ADM confirmed the depression diagnoses and acknowledged they were not included on the PASARR forms, which should have been updated to reflect these mental health conditions.
Surveyors identified that a medication cart at the nurse’s station was left unlocked and unattended, contrary to facility expectations that carts remain locked when not in use, as confirmed by an RN and the DON. In addition, review of medication room refrigerator logs and direct observation showed temperatures repeatedly above the acceptable 36–46°F range, including readings of 48–65°F on several logged days and 50°F on the day of observation. A CMA and the DON both acknowledged the required temperature parameters and confirmed that the documented and observed temperatures were too high, creating a risk that medications stored there could become ineffective and unusable.
Surveyors found that two residents lacked any documented COVID-19 vaccine education, offering, or consent/declination forms in their medical records. Facility COVID-19 consent and education logs showed no completed forms for these residents, indicating they were not documented as having been offered vaccination. The IP reported that the residents’ POAs were unavailable when vaccines were administered and that one resident verbally declined the vaccine but never signed a declination form. The DON stated that all residents are expected to receive education and an offer of vaccination, with consents scanned into the chart and multiple attempts made to reach POAs, but confirmed this documentation was missing for both residents.
A resident with mental health diagnoses, including anxiety disorder and PTSD, was receiving Gabapentin three times daily for anxiety/seizure disorder without a completed and signed psychotropic medication consent form, as required by facility policy. Review of records showed no consent form for Gabapentin, and the DON confirmed that all psychotropic medications should have a consent form and acknowledged that the absence of this form affected the resident’s right to be informed about the medication and its potential side effects.
A resident with multiple medical conditions, including epilepsy, depression, HTN, and hypothyroidism, had a completed MOST form indicating DNR status, but staff did not update the comprehensive care plan to include this active code status. The care plan only referenced educating the resident and POA about health directives and having the physician complete a MOST form, despite the existing DNR order. The DON confirmed that advance directives are expected to be included in care plans and acknowledged that the resident’s code status was missing from the care plan.
The facility failed to ensure proper disposal of garbage and refuse when the outdoor trash bin was observed left open, with one side of the lid broken and unable to close. According to the Dietary Manager, the lid had been broken for several months, allowing the possibility for pests or rodents to access the trash and creating a hazard to staff and residents.
A resident with severe cognitive impairment was physically restrained by CNAs during toileting after becoming combative, resulting in a skin tear and bruising. Facility policy prohibits rough handling and requires staff to manage behaviors without causing injury or distress, but staff held the resident's hands across the chest to prevent striking, which was confirmed through interviews and documentation.
The facility did not provide adequate orientation or training for new and existing nursing staff, lacking formal policies and competency records. Leadership interviews confirmed that no onboarding process was in place until recently, and staff competency verification procedures were still being developed.
Several direct care staff, including a CNA and an RN, provided resident care without having received required training on abuse, neglect, and exploitation. Facility leadership and staff interviews revealed that there was no established onboarding or training verification process in place until recently, resulting in a lack of documentation and unclear responsibilities for ensuring staff competency.
A resident with dementia alleged being attacked by a male staff member, resulting in a thumb injury. The facility did not complete or document a timely and thorough investigation, and failed to provide confirmation that the required Five Day Follow-Up Report was promptly submitted to the State Agency. The report was ultimately received by the State Agency more than two months after the incident.
A resident with multiple chronic conditions died unexpectedly after offsite dialysis, and the facility did not report the death to the State Survey Agency, initiate an internal investigation, or document clinical findings in the medical record. Staff interviews confirmed that no incident report or mortality review was completed because the death occurred offsite.
A resident who died after being transported to dialysis was not properly documented in the facility's progress notes, and the discharge report inaccurately listed the resident as discharged to home instead of deceased. Facility leadership confirmed the documentation errors and stated that records should accurately reflect resident deaths.
Medications, including controlled substances stored in an E-Kit, were placed in a supply room accessible to all staff due to a keypad with a security flaw, allowing entry without a code. The supply room, used for personal care supplies, was accessible to CNAs and other non-licensed staff, contrary to facility policy that restricts access to controlled medications. Facility leadership and maintenance were unaware of the security vulnerability, resulting in medications not being properly secured.
Staff failed to maintain the dishwashing machine at the manufacturer's required minimum temperature of 120°F, with temperature logs showing repeated substandard readings. The facility's policy did not specify required temperatures, and staff continued to use the machine despite knowing it was not reaching proper levels, potentially affecting all residents due to improper dish sanitation.
A resident in a long-term care facility experienced sexual abuse by another resident, leading to significant psychosocial harm. Despite the facility's investigation and actions taken after the incident, the affected resident became withdrawn, experienced acute stress syndrome, and expressed a desire to leave the facility due to fear and lack of support.
The facility failed to ensure staff followed contact precautions for a resident with MRSA, as a housekeeper and CNA entered the room without protective gear. Additionally, the facility lacked a documented water management program to minimize Legionella risk, affecting all residents.
The facility did not designate a qualified Infection Preventionist (IP) to manage the infection prevention and control program (IPCP). After the resignation of the previous Director of Nursing, a nurse reported not being involved in infection control duties and lacking the necessary qualifications. The Interim Administrator confirmed that no official assignment of infection control responsibilities was made to the current staff.
The facility did not ensure CNAs received required dementia and abuse prevention training. A review showed 12 CNAs lacked this training. Interviews confirmed the training list was current and all staff should complete it. The Nurse Educator noted a training session occurred, but only attendees were documented, with no records for those absent.
A resident with impaired vision did not receive necessary vision services due to the facility's failure to schedule an appointment and arrange transportation. Despite the resident's request for assistance and a care plan goal to arrange annual consultations, an appointment was canceled without rescheduling following a facility evacuation due to a roof leak.
A resident with multiple health issues, including a pressure ulcer, did not receive necessary wound care for two days, leading to worsening conditions. The care plan required daily treatment, but the RN failed to perform the care as ordered, resulting in soiled bandages and increased drainage.
The facility failed to secure medications, as a nurse placed the medication room key in an unlockable drawer at the nursing station, which was sometimes unattended. Staff interviews revealed issues with key management, including CMAs being unavailable and keys being lost. The Interim Administrator and Pharmacist stated that keys should be kept on the person of nurses or CMAs to secure medications.
A facility failed to educate a resident's legal guardian on the benefits and potential side effects of the pneumococcal vaccine before obtaining consent. The legal guardian confirmed that no discussion occurred, and the nurse responsible for the oversight was no longer employed at the facility.
A resident with multiple diagnoses, including dementia and heart failure, experienced four falls in one month, three of which resulted in injury. The facility failed to update the resident's care plan until over a month later and did not complete updated fall assessments for two of the falls, leading to a deficiency in care planning.
A resident with dementia and Parkinson's disease was found with an injury of unknown origin to her right ankle. The LPN on duty failed to assess the injury immediately and did not notify the resident's POA or healthcare provider within the required two-hour timeframe. The injury was not assessed until two days later, resulting in a deficiency in the facility's notification procedures.
Unsanitary Beverage Service and Improper Food Storage and Handling
Penalty
Summary
The deficiency involves failure to store, prepare, and serve food and beverages under sanitary conditions. During a dining service observation, an RN was seen serving drinks to residents while gripping cups by the rim with bare hands on multiple occasions. In a subsequent interview, the RN reported having worked at the facility for six months and stated he had not received specific training related to dining service and distributing drinks to residents, although he acknowledged that cups should not be gripped from the top and should be handed to residents by holding the side. The Food Service Director later confirmed that her expectation is that staff assisting with dining service do not touch the rim of cups when serving, and that cups should be held by the side to avoid cross contamination and infection. A follow-up kitchen tour revealed multiple food storage and sanitation issues. Surveyors observed 21 cans of corn in dry storage with an expiration date of 12/28/2025, a cracked 6-lb container of frozen sliced strawberries left open to air in the freezer, and a 1-gallon container of whole milk past its expiration date that could not be sealed in the refrigerator. They also observed a 1-gallon container of Golden Italian dressing and a 1-gallon container of barbecue sauce with large amounts of spilled product on the sides of the containers in the refrigerator. In an interview, the Dietary Manager stated frozen foods should be discarded after one year in the freezer, staff are expected to check food expiration dates weekly, expired food must be discarded, and that the kitchen should not contain expired items, that food and beverages should be stored appropriately, and that spilled liquids should be cleaned.
Inaccurate PASARR Screenings for Residents With Depression
Penalty
Summary
The deficiency involves the facility’s failure to ensure Level 1 PASARR screenings were reviewed for accuracy and completion for four residents with documented mental health diagnoses. Record review showed that one resident was initially admitted with a diagnosis of depression, and this diagnosis was also documented on the resident’s MDS dated 01/15/26. However, the resident’s PASARR Level 1 Identification Screen dated 07/29/24 indicated “No” to having a diagnosis or suspected mental illness, and the depression diagnosis was not reflected on the PASARR. For a second resident, the face sheet showed admission with certain diagnoses, and the PASARR Level 1 dated 01/10/26 documented no diagnosis or suspected mental illness, while the MDS indicated a diagnosis of depression and use of an antidepressant. For a third resident, the PASARR Level 1 dated 02/05/26 documented no diagnosis or suspected mental illness, while the face sheet listed diagnoses at admission and the MDS showed a diagnosis of depression and receipt of an antidepressant. For a fourth resident, the PASARR Level 1 dated 08/26/25 also indicated no diagnosis or suspected mental illness, despite the face sheet listing admission diagnoses and the MDS documenting depression and antidepressant use. In an interview on 03/12/26, the Administrator confirmed that all four residents had diagnoses of depression and acknowledged that these mental health diagnoses were not reflected on their PASARRs, and that updated PASARRs should have included the depression diagnoses.
Unlocked Med Cart and Improper Medication Refrigerator Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to properly secure a medication cart and to maintain appropriate storage temperatures for medications. During an observation at the nurse’s station, one medication cart used for storage, transport, and administration of medications was found unlocked and unattended. In interviews, an RN stated that medication carts should always be locked when unattended and acknowledged that leaving them unlocked could allow residents and visitors access to medications. The DON similarly stated her expectation that medication carts be locked at all times when unattended and confirmed that if carts are left unlocked, anyone could access the medications. The facility also failed to maintain the medication storage room refrigerator within the required temperature range of 36 to 46 degrees Fahrenheit. Review of the refrigerator temperature logs for a two-month period showed recorded temperatures of 65°F on one date and 48°F on two other dates. During an observation of the medication room, both the built-in and portable thermometers in the medication refrigerator showed a temperature of 50°F. A CMA stated the refrigerator temperature should be around 42°F and not more than 46°F, and confirmed the observed 50°F reading. The DON stated that the medication refrigerator temperature should be within the appropriate range, documented daily, and confirmed that 50°F was too warm and that medications not stored at the correct temperature can become ineffective and unusable for residents.
Failure to Document COVID-19 Vaccine Education and Offering for Two Residents
Penalty
Summary
The facility failed to ensure that residents' medical records contained documentation of education, offering, or administration of the COVID-19 vaccination for two of five residents reviewed. Record review showed that one resident was admitted on a specified date, but there was no completed COVID-19 vaccination consent and education form in the facility’s COVID-19 consent and education documentation, indicating the resident was not offered the vaccine. Similarly, another resident admitted on a specified date also had no completed COVID-19 vaccination consent and education form in the documentation provided by the facility, likewise indicating that this resident was not offered the COVID-19 vaccine. During an interview, the Infection Preventionist stated that at the time COVID-19 vaccines were being administered, the powers of attorney for both residents were unavailable to provide consent. The Infection Preventionist reported that one of the residents verbally stated he did not want the vaccination and would have been able to sign a consent form declining the vaccine, but this was not done. The Infection Preventionist confirmed that neither resident had completed COVID-19 consent and education forms and that they should have. In a separate interview, the DON stated that her expectation is that every resident be educated and offered the COVID-19 vaccination, that consent forms are scanned into the chart, and that multiple attempts should be made to contact the POA; she confirmed that neither of the two residents had completed COVID-19 consent and education forms and that they should have.
Failure to Obtain Psychotropic Medication Consent for Gabapentin
Penalty
Summary
The facility failed to obtain a completed and signed psychotropic medication consent form prior to administering a psychotropic medication to a resident. The facility’s psychotropic medication use policy, last revised in July 2022, defined psychotropic medications as those affecting brain activity and included antipsychotics, antidepressants, antianxiety medications, and hypnotics. Record review showed that a resident was admitted with diagnoses including a manic episode, anxiety disorder, and PTSD. Physician orders dated 8/24/25 directed administration of Gabapentin 100 mg by mouth three times daily for anxiety/seizure disorder. Review of the resident’s psychotropic medication consent forms dated 03/12/26 revealed that no consent form for Gabapentin had been completed or was available. During an interview on 03/12/26 at 2:00 p.m., the DON stated that any medication listed as a psychotropic should have a consent form and acknowledged that the resident did not have a consent form completed for Gabapentin use, despite one being required. The DON further stated that the lack of a psychotropic consent form affected resident rights, as residents have the right to know what medications they are receiving and to be informed of potential side effects.
Failure to Update Care Plan With Resident’s DNR Code Status
Penalty
Summary
Facility staff failed to revise and update a resident’s comprehensive care plan to include the resident’s current advance directive code status. Record review showed the resident was admitted with diagnoses including generalized idiopathic epilepsy with status epilepticus, depression, hypertension, and hypothyroidism. A Medical Orders for Scope of Treatment (MOST) form dated 02/11/2026 documented the resident’s code status as Do Not Resuscitate (DNR). However, the resident’s current care plan, dated 02/13/2026, did not include the active code status. Instead of documenting the resident’s DNR status, the care plan only indicated that staff would educate the resident and the resident’s Power of Attorney regarding health directives and have the physician complete a MOST form, despite the MOST form already being completed and specifying DNR. During an interview on 03/10/2026 at 2:14 pm, the DON stated it was her expectation that residents’ advance directives be included in their care plans and confirmed that this resident’s care plan did not include the advance directive code status and that it should have.
Failure to Maintain Covered Outdoor Trash Bin
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not maintaining the outdoor trash bin in a covered condition. On 03/12/26 at 11:37 a.m., surveyors observed the outdoor trash bin left open, with only one side of the lid able to be closed and the other side broken. During an interview at 11:50 a.m. the same day, the Dietary Manager stated that the outdoor trash bin lid was broken and that they had been trying to fix the lid for the last six months. She also stated that pests or rodents can get into the trash and that it is a hazard to staff and residents. The report notes that if staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to residents.
Inappropriate Use of Physical Restraint During Resident Care
Penalty
Summary
Facility staff failed to protect a resident with severe cognitive impairment, including diagnoses of unspecified dementia and Alzheimer's disease, from inappropriate use of physical restraint during care. According to interviews and record reviews, two CNAs attempted to assist the resident with toileting when the resident became combative, swinging arms and attempting to strike staff. In response, one CNA held the resident's hands across the chest to prevent hitting, which is considered a form of physical restraint. The facility's policy prohibits rough handling and requires staff to manage behaviors in a way that prevents injury, pain, or distress. Documentation revealed that following the incident, the resident was found to have a skin tear on the right lower abdomen and a large bruise on the right hand. Staff interviews confirmed that the restraint was applied during care, and the Assistant Director of Nursing acknowledged that staff should have stepped away and notified nursing staff rather than continuing care during combative behavior. The Administrator confirmed that restraining residents during care is not acceptable per facility expectations and policy.
Lack of Staff Competency Due to Inadequate Orientation and Training
Penalty
Summary
The facility failed to ensure that nurse aides and nursing staff were competent to perform their assigned duties due to a lack of adequate orientation and training for both new and existing employees. Record review revealed that the facility did not have a formal policy or process in place for onboarding, orientation, or training of staff. Additionally, the facility was unable to provide training and competency records for several staff members, including certified nurse aides and a registered nurse. Interviews with facility leadership confirmed that there was no onboarding process for staff prior to July of the current year. The Assistant Director of Nursing (ADON) acknowledged oversight of CNA training but stated that no onboarding process existed before that time. The Human Resources Director, who had only recently joined the facility, also confirmed the absence of a formal onboarding process for nursing staff. The Staffing Coordinator and Director of Nursing further corroborated that there were no established policies or procedures for staff onboarding or competency verification, and that the process was still under development.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received training on abuse, neglect, and exploitation prior to providing direct resident care. Record review showed that there was no documentation of such training for several staff members, including Certified Nurse Aides and a Registered Nurse. Interviews with staff and leadership revealed that there was no onboarding process in place until recently, and responsibilities for verifying staff qualifications and training were unclear among the Assistant Director of Nursing, Staffing Coordinator, and Human Resources. The Director of Nursing confirmed that policies and procedures for onboarding and competency verification were not established when she began her employment, and the process was still under development at the time of the survey. Direct care staff, including a Registered Nurse and a Certified Nurse Aide, confirmed during interviews that they had not received abuse, neglect, and exploitation training, despite already providing resident care. The Administrator acknowledged awareness of the training and competency issues and stated that efforts were underway to organize records and implement a tracking process for staff trainings. There were no details provided about specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to complete and document a timely and thorough investigation regarding an allegation of abuse involving a resident with dementia and behavioral issues. The incident involved the resident alleging that she was attacked by a male staff member during the night shift, resulting in a thumb injury, but she was unable to provide specific details or identify the staff member. The facility's Five Day Follow-Up Report, which is required to be sent to the State Agency to document the results of the investigation, was undated and the facility could not provide confirmation that the report was received by the State Agency. State Agency records showed the report was not received until over two months after the incident, and the Director of Nursing was unable to provide evidence of timely submission.
Failure to Report Unexpected Resident Death and Initiate Investigation
Penalty
Summary
The facility failed to report an unexpected death of a resident to the State Survey Agency and did not initiate an internal investigation or document clinical findings in the medical record following the event. The resident, who had diagnoses including end-stage renal disease, chronic respiratory failure with hypoxia, diabetes mellitus, and hypertension, passed away after attending dialysis offsite. Despite the unexpected nature of the death, the facility did not complete an incident report or conduct a mortality investigation. Interviews with facility staff, including the ADON and Administrator, confirmed that no formal review or report was submitted to the State Survey Agency because the death occurred offsite. The Medical Director was notified of the death and stated an expectation that the facility would notify the State Survey Agency in such cases. Review of the resident's progress notes and records showed no evidence of an internal investigation or reporting of the event.
Failure to Accurately Document Resident Death and Discharge Status
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical record for a resident who died after being transported to dialysis. Staff did not document in the progress notes that the resident was transported to dialysis and subsequently died at the dialysis center. Additionally, the facility's Admit/Discharge Report inaccurately listed the resident as discharged to home or self-care, rather than deceased. During interviews, the Assistant Director of Nursing confirmed the resident's death after dialysis, and the Administrator acknowledged the discharge status was not updated to reflect the resident's death. The Medical Director stated that staff are expected to document resident deaths in the clinical record and ensure records accurately reflect the resident's status.
Medications and Controlled Substances Not Properly Secured
Penalty
Summary
The facility failed to ensure that medications, including controlled substances, were properly secured and inaccessible to unauthorized staff. According to the facility's own policy, only authorized licensed nursing and pharmacy personnel should have access to controlled medications, and the access system for these medications should be separate from that used for non-scheduled medications. However, observations revealed that the supply room, which contained over-the-counter medications and an emergency kit (E-Kit) with controlled substances such as morphine, Xanax, and Temazepam, could be accessed by all staff, including CNAs, due to a keypad with an exposed spring that allowed the door to be opened without entering a security code. The E-Kit and medications had been moved to the supply room following a pharmacist's recommendation due to temperature concerns in the medication room. Interviews confirmed that the supply room was accessible to all facility staff because it also contained personal care supplies needed for residents. The DON acknowledged that the E-Kit in the supply room posed a potential hazard since controlled medications were accessible to unauthorized staff. Maintenance staff were unaware of the security flaw with the keypad, and the Administrator confirmed that all staff had access to the room and was not aware that the security code could be bypassed. These actions and inactions resulted in medications not being properly secured as required by facility policy and regulatory standards.
Failure to Maintain Required Dishwashing Temperatures for Proper Sanitation
Penalty
Summary
The facility failed to properly sanitize dishes due to not maintaining the dishwashing machine at the required minimum temperature of 120°F, as specified by the manufacturer's instructions. The facility's dishwashing policy did not address the necessary water temperature for sanitizing dishes, and temperature logs for the dishwashing machine consistently showed wash temperatures below 120°F over a period of several days. Staff, including the Dietary Manager and kitchen staff, were aware that the dishwashing machine was not reaching the appropriate temperature, and the Registered Dietician noted that at least half of the recorded temperatures for the month were below the required level. The dishwashing machine was identified as a low-temperature, chemical sanitizing model, but both the manufacturer’s recommendations and the machine’s name plate indicated that a minimum temperature of 120°F was necessary for effective sanitation. Despite being aware of the issue, staff continued to use the dishwashing machine for cleaning dishes and cooking equipment, and the Administrator acknowledged not knowing the correct temperature for the wash and rinse cycles. The outside lab technician confirmed that the machine required a boost heater to reach the necessary temperature. The deficiency was likely to affect all 33 residents in the facility, as the improper sanitization of dishes could expose them to foodborne illnesses.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse, resulting in psychosocial harm and distress for a resident. The incident involved a male resident entering the room of a female resident, who was asleep, and engaging in non-consensual sexual activity. The female resident, who had a history of depressive disorder and chronic pain, reported the incident to the nursing staff the following day. The facility was notified, and an investigation was initiated, but the incident had already caused significant emotional distress to the resident. The resident experienced acute stress syndrome following the incident, as diagnosed by a psychiatrist. She became more withdrawn, isolated, and expressed fear and anxiety about staying in the facility. The resident's psychosocial assessment indicated that she was staying in her room more often and had nightmares related to the incident. Her weight also decreased significantly over the following months, indicating a decline in her overall well-being. The facility's response included notifying the resident's Power of Attorney and arranging for a Sexual Assault Nursing Exam (SANE) at the hospital. However, the resident continued to express a desire to leave the facility due to fear and lack of support. The facility's investigation report noted that the male resident was placed on one-to-one supervision and later discharged, but the female resident's condition continued to deteriorate, highlighting the facility's failure to protect her from abuse and provide adequate support after the incident.
Failure to Follow Contact Precautions and Lack of Water Management Program
Penalty
Summary
The facility failed to ensure that staff adhered to contact precautions for a resident who was admitted with methicillin-resistant Staphylococcus aureus (MRSA) in a coccyx wound. Observations revealed that a housekeeper and a certified nurse assistant (CNA) entered the resident's room without wearing gloves or an isolation gown, despite a contact precautions sign on the door instructing staff to do so. The housekeeper was unaware of the contact precautions, and the CNA believed protective gear was only necessary when cleaning the resident's wound. A nurse confirmed that both staff members were expected to follow the contact precautions. Additionally, the facility did not have a documented water management program to minimize the risk of Legionella and other pathogens in the building's water systems. Interviews with the maintenance technician and the facility's administrator revealed that there was no water testing system or related documentation in place. This lack of a water management program affected all residents in the facility, increasing the risk of exposure to Legionella bacteria.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the infection prevention and control program (IPCP). This deficiency was identified through interviews and record reviews. During an interview, a nurse stated that the previous Director of Nursing, who resigned at the end of November 2024, did not involve her in the infection control process, and she was not asked by the Interim Administrator to perform any infection control duties. Furthermore, she lacked the qualifications to carry out infection prevention and control tasks. The Interim Administrator confirmed that the previous Director of Nursing managed infection control reporting and that neither the interviewed nurse nor the current senior ranking nurse was officially assigned any infection control responsibilities.
Deficiency in CNA Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required training in dementia care and abuse prevention. A review of the facility's training records from December 2023 to December 2024 revealed that 12 out of 19 CNAs did not receive the necessary training. Interviews with the Social Services Director and the Interim Administrator confirmed that the training list was current and that all nursing staff were expected to complete the trainings. The Nurse Educator stated that a dementia training session was held on November 26, 2024, but only those who signed the attendance sheet participated, and there was no documentation for those who missed the session to show they had reviewed the training materials.
Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
The facility failed to assist a resident in gaining access to vision services, as evidenced by the lack of appointment scheduling and transportation arrangements for the resident. The resident, who had impaired vision as documented in both the Admission and Quarterly Minimum Data Sets, expressed that she had requested assistance from staff to schedule an eye appointment earlier in the year but did not receive a response. The resident's care plan, dated 10/4/24, included a goal to arrange for an Ophthalmologist or Optometrist consultation annually and as needed, which was not fulfilled. Nurse #4 confirmed that an eye appointment was initially scheduled for the resident on 6/14/24, but it was canceled due to a lack of transportation. Following the cancellation, the facility experienced a widespread roof leak that necessitated an evacuation, and the appointment was not rescheduled. This series of events led to the resident not receiving the necessary vision services, which could potentially impact her health and quality of life.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with pressure ulcers, leading to a worsening of the condition. The resident, who was initially admitted with multiple diagnoses including muscle wasting, type 2 diabetes with neuropathy, and stage 4 chronic kidney disease, was readmitted with a Stage 2 pressure ulcer on the coccyx. The care plan outlined that the resident's wounds should heal without complications and specified that staff should provide care according to the provider's orders, including sending the resident to the emergency room for evaluation and treatment as needed. However, the facility did not adhere to the physician's orders for wound care, which included daily cleansing and dressing of an unstageable pressure ulcer on the sacrum. The Wound Care Nurse reported that the resident's wound care was neglected for two consecutive days, resulting in grossly soiled bandages with significant blood and drainage. The Director of Nursing's follow-up report confirmed that the assigned RN failed to complete the required daily wound care on the specified dates, contributing to the deterioration of the resident's condition.
Medication Security Lapse in Facility
Penalty
Summary
The facility failed to ensure that medications were secured and inaccessible to unauthorized staff and residents. During an observation, a nurse was seen placing the medication room key inside an unlockable drawer at the nursing station. This practice was confirmed by the nurse, who stated that someone was always present at the nursing station to guard the drawer. However, an observation later revealed that the nursing station was unattended, leaving the key and potentially the medication room unsecured. Interviews with staff revealed further issues with key management. A nurse mentioned that Certified Medication Aids (CMAs) were responsible for holding the medication room key, but they were not always available when needed. Additionally, keys were often lost when staff took them home, prompting the decision to keep the key in the drawer. The facility's Interim Administrator and Pharmacist both expressed that the key should not be kept in an unlocked drawer and should be kept on the person of the nurses or CMAs to ensure the security of medications, including insulin and over-the-counter drugs.
Failure to Educate Legal Guardian on Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a nurse provided education to a resident's legal guardian about the benefits and potential side effects of the pneumococcal immunization before offering the immunization. This deficiency involved a resident whose legal guardian was her son. The physician's order to administer the Prevnar vaccine was dated 11/25/24, and the legal guardian had consented to the immunization. However, the progress notes from 11/19/24 indicated that Nurse #5 called the legal guardian to obtain consent but did not document any education on the benefits or potential side effects of the vaccine. During an interview, the legal guardian confirmed that the nurse did not discuss these aspects. Nurse #4 stated that she expected Nurse #5 to provide this education, but Nurse #5 was no longer employed at the facility.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after multiple falls, which is a deficiency in care planning. The resident, who was admitted with diagnoses including heart failure, anxiety disorder, restlessness, agitation, and unspecified dementia, experienced four falls in August 2024. These falls included one without injury and three with injuries. Despite the falls, the facility did not update the resident's care plan until late September 2024. Additionally, the facility did not complete updated fall assessments for two of the falls that occurred in August, further contributing to the deficiency in care planning.
Failure to Notify POA and Provider of Resident Injury
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) and healthcare provider of a resident when staff discovered an injury of unknown origin. The resident, who had dementia and Parkinson's disease, was found with an injury to her right ankle. Despite being informed of the injury, the Licensed Practical Nurse (LPN) on duty did not assess the injury immediately and instead passed the information to an incoming night nurse without ensuring the assessment was completed. The injury was not assessed until two days later when the LPN returned from days off. The Director of Nursing (DON) confirmed that the staff did not notify the resident's POA or the on-call provider about the injury within the required two-hour timeframe. The facility's policy mandates that such notifications be made promptly to allow the POA and provider to make informed decisions regarding the resident's care. The delay in notification and assessment resulted in a failure to comply with the facility's procedures for handling injuries of unknown origin.
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.
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