Lovington Healthcare Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lovington, New Mexico.
- Location
- 1600 West Avenue I, Lovington, New Mexico 88260
- CMS Provider Number
- 325057
- Inspections on file
- 22
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lovington Healthcare Llc during CMS and state inspections, most recent first.
The facility did not post up-to-date nurse staffing information at the start of the shift, as required. The posted data was from the previous day and did not include current details such as the facility name, date, staffing hours for RNs, LPNs, CNAs, or the resident census. This was confirmed by the MDS Coordinator and had the potential to affect all residents in the facility.
A medication cart near the 300 hall was found unlocked and unattended, as confirmed by a facility scheduler who stated it should always be locked when not attended. This lapse had the potential to impact all 17 residents on the 300 hall.
Surveyors observed multiple large boxes, packaging materials, and a toilet obstructing the hallway in the 300 hall, impeding resident access. A staff member confirmed that these items were blocking the path and acknowledged that hallways should remain clear for resident movement.
Staff failed to follow safe food handling practices, including improper handling of cups by touching the rim, failure to label and date a drink pitcher in the refrigerator, and not properly wearing hairnets in the kitchen. These deficiencies in food preparation and service under sanitary conditions were confirmed by supervisory staff and could affect all residents in the facility.
Surveyors found that staff did not update care plans for five residents to accurately reflect current interventions, such as the use or discontinuation of mobility bars, positioning rails, pain management, and psychotropic medications. In each case, care plans either omitted new interventions or continued to list interventions that were no longer in use, despite supporting documentation and staff confirmation that updates were needed.
Surveyors observed that mechanical lifts, a housekeeping cart, and a medication cart were left on both sides of a hallway, blocking the path for residents. A receptionist confirmed that these items were not properly stored, resulting in an obstructed hallway.
A resident with documented diagnoses of major depressive disorder, PTSD, and schizoaffective disorder was admitted, but staff incorrectly completed the PASRR assessment by indicating no mental illness. The Interim DON confirmed the error during an interview.
A resident with multiple respiratory conditions was receiving oxygen therapy without a comprehensive, person-centered care plan or a physician order. The care plan lacked details on baseline vital signs, frequency, and indication for oxygen use, and staff confirmed these omissions during interviews.
A resident with multiple respiratory diagnoses was observed receiving oxygen therapy via nasal cannula, confirmed by staff, without a corresponding physician order documented in the electronic health record.
Two residents requiring oxygen therapy were observed with undated and unbagged oxygen tubing and cannulas, with some equipment found on the floor or on wheelchairs. The MDS Coordinator confirmed that oxygen supplies were not changed weekly as ordered and were not properly stored, contrary to facility expectations.
A resident with significant mobility and communication impairments was not provided with an accessible or usable call light. The call light was found on the floor and, when in hand, the resident was unable to activate it due to physical limitations. Staff confirmed the standard call light was not appropriate for the resident's needs.
A facility failed to ensure privacy for a resident during personal care, as a nurse did not pull the privacy curtain closed while treating a Stage 3 pressure ulcer, leaving the resident exposed to his roommate. The resident's daughter noted that her father would feel embarrassed by such exposure, and the facility's Administrator confirmed that privacy curtains should be used to maintain resident privacy.
A resident with a history of stroke and muscle weakness was not repositioned according to her care plan, which required repositioning every two hours to prevent skin issues. Observations showed the resident was not moved as scheduled, and staff interviews revealed confusion about the repositioning clock and documentation responsibilities.
The facility failed to accurately document tube feeding and hydration for two residents, leading to potential confusion about the care provided. One resident with stroke and dysphagia had significant lapses in documentation of Jevity and hydration flushes, while another resident with acute respiratory failure and gastrostomy status had discrepancies in the documentation of Glucerna and water flushes. Interviews confirmed that these procedures should have been documented each time they were performed.
A resident who was admitted after brain surgery did not receive prescribed hydrocodone-acetaminophen for pain management, despite severe pain levels documented. The facility staff failed to administer the medication due to its unavailability, leading the resident and his wife to leave against medical advice. Interviews revealed that the medication was available in the facility's dispensing cabinet but was not used.
The facility failed to update staffing sheets at the beginning of each shift, resulting in outdated and unclear information being posted. This issue persisted over several days, contrary to the facility's policy. The DON and Administrator confirmed the requirement for daily updates.
The facility failed to ensure that opened insulin flex pens and prefilled syringes were properly dated when initially opened by nursing staff. Additionally, expired supplies were not kept separate from unexpired supplies, as observed in the 100-medication cart. An LPN and the Director of Nursing confirmed these deficiencies.
The facility failed to monitor and maintain the internal temperature of food at safe levels, with pork chops served at 129°F instead of the required 135°F. This deficiency could affect all 56 residents consuming food from the kitchen.
The facility failed to maintain proper infection prevention measures during medication administration and the use of medical equipment. Staff did not sanitize their hands before or after administering medications to three residents and did not sanitize the blood pressure cuff after using it on five residents. Additionally, an oxygen cannula was found on the floor and subsequently placed into a resident's nose without being replaced or sanitized.
The facility failed to ensure kitchen equipment was in safe operating condition. One section of the steam table was non-functional, with the water in the steam well cool to the touch and no steam present. A pan of pork chops placed in the well measured 129 degrees Fahrenheit. The Dietary Director confirmed the issue.
The facility failed to ensure that a resident, their representative, and the Ombudsman received a written notice of transfer as soon as practicable. The resident had an unplanned discharge to a hospital, and the DON confirmed there was no documentation of Ombudsman notification.
The facility failed to maintain records of controlled substances on each medication cart, as staff did not sign the narcotic book to show they counted the medication blister pill cards and compared them to the residents' medication sheets. A CMA and the DON confirmed the missing signatures and the requirement for staff to sign the narcotic book at the beginning and end of each shift.
The facility failed to monitor and document side effects of medications for two residents, including anticoagulants and insulin, as confirmed by the DON. This lack of monitoring occurred in both February and March 2024, potentially leading to adverse outcomes.
The facility failed to ensure the MDS was accurate for two residents. One resident's MDS incorrectly indicated the use of an anticoagulant, while another resident's MDS did not reflect a diagnosed psychotic disorder. The MDS Coordinator confirmed these errors during interviews.
The facility failed to develop and implement a comprehensive care plan within 21 days of readmission for a resident. The care plan had all items marked as resolved or cancelled, and the MDS Coordinator was unaware of the reason, confirming that the items should still be effective.
The facility failed to update a resident's diagnosis for the use of a medication and did not follow the physician's order regarding liquid consistencies for another resident. The discrepancies were confirmed by the DON and observed during a dining room incident.
A resident reported missing top dentures and was observed with several missing teeth. Despite a care plan indicating the need for dentures and a dental note recommending a follow-up appointment, the resident did not receive the necessary dental services.
A resident with dysphagia was not provided with properly thickened liquids, leading to difficulty swallowing and coughing. The resident's medical record, care plan, and physician orders lacked necessary information, and the care plan was not coordinated with the meal ticket.
The facility failed to ensure staff offered COVID-19 vaccinations to three residents. One resident's EHR did not show the vaccine offer, and the DON could not provide declination documentation. Another resident received the first dose but not the second, and a third resident had no documentation of subsequent vaccine offers after the initial dose.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information at the beginning of each shift as required. During an observation at the main entrance, the posted nurse staffing data was found to be outdated, displaying information from the previous day rather than the current date. The required posting should have included the facility name, current date, total number and actual hours worked by registered nurses, LPNs, certified nurse aides, and the resident census for each shift. This deficiency was confirmed during an interview with the MDS Coordinator, who acknowledged that the staffing data had not been posted for the current day. The issue had the potential to affect all 58 residents in the facility, as identified by the administrator's census.
Unattended Unlocked Medication Cart
Penalty
Summary
A medication cart located near the 300 hall was observed to be unlocked and unattended during a facility observation. This incident was confirmed by the facility scheduler, who acknowledged that the medication cart should be locked at all times when not attended. The unlocked cart had the potential to affect all 17 residents residing on the 300 hall, as identified by the facility census provided by the Administrator.
Obstructed Hallway Due to Improper Storage of Boxes and Equipment
Penalty
Summary
The facility failed to ensure that the hallway in the 300 hall was accessible for residents, as observed during a random inspection. On the specified date and time, three large boxes, including one with a picture of a toilet, were found piled on top of each other along with other pieces of cardboard and packaging material protruding from the top and sides, obstructing the hallway near a resident room. Additionally, a large box with a picture of a toilet and a toilet itself were found on the floor in the hallway near other resident rooms. During an interview, a facility payroll staff member confirmed that objects were present on both sides of the hallway, blocking the path for residents, and stated that items should be kept on one side to maintain a clear passage.
Deficient Food Handling and Sanitation Practices in Kitchen and Dining Areas
Penalty
Summary
Staff failed to follow safe food handling practices, as evidenced by transportation personnel serving residents cups by touching the rim with bare hands. This was confirmed by the MDS Coordinator, who stated that the expectation is for staff to handle cups by the sides and avoid touching the rim. Additionally, a drink pitcher containing a brown liquid was found in the main refrigerator without a label indicating its contents or preparation date. The Dietary Aide admitted to forgetting to place the label on the pitcher before returning it to the refrigerator, despite having the label in her pocket. Further observations revealed that a dishwasher was not properly wearing a hairnet, with hair hanging out and not fully covered. This was observed on two separate occasions and confirmed by both the dishwasher and the Dietary Supervisor, who stated that all staff are expected to properly wear hairnets while in the kitchen or serving food. These practices were identified as deficiencies in food preparation and service under sanitary conditions, potentially affecting all 59 residents in the facility.
Failure to Revise Care Plans to Reflect Current Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner for five residents, as required by regulations. For one resident, although a safety device evaluation, physician order, and consent for bed mobility bars were completed, the care plan was not updated to reflect the use of these devices, despite their presence in the resident's room and the resident's stated use of them for positioning. Another resident had an order for positioning rails, and these were in use, but the care plan did not include any information about them. In both cases, the Interim Director of Nursing (IDON) confirmed that the care plans should have been revised to include these devices. A third resident's care plan continued to reference repositioning bars, even though there was no assessment, order, or consent for their use, and the bars were not present in the resident's room. The resident confirmed that she no longer used the bars and was unsure when or why they were removed. The IDON acknowledged that the care plan was not updated to remove this intervention. Similarly, another resident's care plan included interventions for pain medication administration, but there were no orders for pain medication, no administration of such medication, and pain monitoring consistently indicated no pain. The IDON stated the care plan was initially created as a preventative measure but was not revised when it became clear the intervention was unnecessary. For the fifth resident, the care plan indicated the use of a psychotropic medication, but the medication had been discontinued and there were no current orders for it. The IDON confirmed that the care plan should have been updated to reflect the discontinuation. In all cases, the lack of timely care plan revisions meant that the documented plans of care did not accurately reflect the residents' current needs and interventions in place at the time of the survey.
Obstructed Hallways Due to Equipment and Carts
Penalty
Summary
The facility failed to ensure that the hallway in the 100 hall was accessible for residents, as observed on two separate occasions. On both days, mechanical lifts were found positioned on both the right and left sides of the hallway near various resident rooms, along with a housekeeping cart and a medication cart also placed on either side of the hallway. These items were observed to be blocking the residents' path. During an interview, the receptionist confirmed that objects were present on both sides of the hallway, obstructing the clear passage that should be maintained for residents.
Inaccurate PASRR Assessment for Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for one resident. Record review showed that the resident was admitted with diagnoses of major depressive disorder, post-traumatic stress disorder (PTSD), and schizoaffective disorder, bipolar type. However, the PASRR completed for this resident indicated that there was no diagnosis or suspicion of mental illness. During an interview, the Interim Director of Nursing confirmed that the resident did have these mental health diagnoses and acknowledged that the PASRR documentation was incorrect.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
Staff failed to develop a comprehensive care plan for a resident who was admitted with multiple respiratory diagnoses, including Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, pleural effusion, acute and chronic respiratory failure with hypoxia, and an anxiety disorder. The care plan in place noted the use of oxygen therapy related to COPD and respiratory therapy, and included an intervention to monitor for signs and symptoms of respiratory distress and report to the provider as needed. However, the care plan lacked person-centered interventions, did not specify baseline vital signs, and did not describe the oxygen therapy in terms of frequency or indication for use. Observation confirmed that the resident was using an oxygen concentrator with a nasal cannula in her room. Review of the electronic health record revealed there was no physician order for the use of oxygen. Staff interviews confirmed the resident was receiving oxygen therapy and that the care plan did not meet expectations for person-centered interventions related to oxygen therapy.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease with acute exacerbation, pleural effusion, acute and chronic respiratory failure with hypoxia, and anxiety disorder was observed using an oxygen concentrator with a nasal cannula in her room. Staff, including a Certified Medication Aid and the Interim Director of Nursing, confirmed that the resident was receiving oxygen therapy. However, a review of the resident's electronic health record revealed there was no physician order for the use of oxygen. The Interim Director of Nursing acknowledged that the resident should have had an order for oxygen use, but none was present at the time of the survey.
Failure to Maintain Infection Control for Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for two residents who required oxygen therapy. For one resident with COPD, anxiety disorder, and anemia, observations revealed that the oxygen tubing and cannula in use were not dated, and the tubing on both the concentrator and portable oxygen were missing date and time labels. During a meal observation, this resident was seen wearing oxygen with tubing and cannula that were not dated or stored in a bag. Another resident with cerebral palsy, diabetes mellitus, seizure disorder, and acute respiratory failure with hypoxia was also found to have deficiencies in oxygen equipment management. The oxygen tubing connected to the concentrator in the resident's room was observed on the floor and, although dated, was not stored in a bag. During a meal observation, this resident was also seen wearing oxygen with tubing and cannula that were not dated or bagged. The MDS Coordinator confirmed these findings and stated that the expectation is for all tubing and cannulas to be changed weekly as ordered and kept in bags, not on the floor or on wheelchairs.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, hemiparesis, generalized muscle weakness, and speech disturbance was not provided with reasonable accommodation for their needs and preferences. The resident was totally dependent on staff for activities of daily living, including the use of the call bell for assistance. During observation, the call light was found on the floor behind the bed, out of the resident's reach, and the resident was unable to use the standard push button call light due to impaired mobility. The resident attempted multiple times to press the call light button but was unsuccessful. Interviews with staff, including Social Services and the Director of Nursing, confirmed that the push button call light was difficult for the resident to use and that a soft touch call light would be more appropriate given the resident's physical limitations. The failure to provide an accessible and usable call light for the resident resulted in the resident being unable to request assistance as needed.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy during personal care for a resident, identified as R #1, who was being treated for a Stage 3 pressure ulcer on his right buttock. During a wound care observation, Registered Nurse (RN) #1 entered R #1's room, closed the door, but did not pull the privacy curtain closed, leaving R #1 exposed to his roommate who was present in the room. This oversight occurred despite the resident's care plan and the expectation set by the facility's Administrator that privacy curtains should be used to ensure resident privacy during personal care, especially when a roommate is present. R #1's daughter expressed that her father, being a proud man, would feel embarrassed by such exposure.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident by not adhering to the prescribed repositioning schedule outlined in the care plan. The resident, who was admitted with diagnoses including stroke, muscle weakness, and dysphagia, had a care plan that required repositioning every two hours to prevent skin integrity issues. Observations revealed that the resident was not repositioned according to the schedule indicated by the repositioning clock in her room. Specifically, the resident was observed lying on her back when she should have been repositioned to her left or right side as per the clock's instructions. Interviews with staff, including an LPN, CNA, and the ADON, indicated a lack of understanding and communication regarding the repositioning schedule. The LPN admitted to not knowing how to read the repositioning clock, while the CNA acknowledged that the resident had not been repositioned as required. The ADON and RNC confirmed that the staff were expected to follow the repositioning clock and document each repositioning event, although documentation was not consistently maintained. This lack of adherence to the care plan and documentation requirements led to the deficiency identified by the surveyors.
Inaccurate Documentation of Tube Feeding and Hydration
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents, leading to potential confusion regarding the services and treatments provided. For the first resident, who was admitted with diagnoses including stroke, muscle weakness, and dysphagia, there were significant lapses in documenting the administration of enteral feeding and hydration flushes. Despite physician orders specifying the administration of Jevity 1.5 and hydration flushes via a PEG tube, the Nurse Administration Record (NAR) showed that staff documented the administration of Jevity only three times out of 60 opportunities in April and 12 times out of 32 opportunities in May. Similarly, hydration flushes were documented only five times out of 150 opportunities in April and 25 times out of 80 opportunities in May. Interviews with nursing staff confirmed that these procedures should have been documented each time they were performed. For the second resident, who was admitted with acute respiratory failure with hypoxia, gastrostomy status, and dysphagia, there were also discrepancies in documentation. The physician orders required the administration of Glucerna 1.5 and water flushes multiple times a day. However, the Medication Administration Record (MAR) indicated that Glucerna was documented 71 times out of 80 opportunities, and water flushes were documented only 36 times out of 96 opportunities. The Regional Nurse Consultant confirmed that the staff failed to document the tube feeding and hydration as required, which could lead to confusion about the care provided to the resident.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to effectively manage pain for a resident who was admitted from the hospital following brain surgery. The resident was prescribed hydrocodone-acetaminophen for pain management, as indicated in the hospital discharge orders and the facility's physician orders. However, the staff did not administer the prescribed pain medication, resulting in the resident experiencing severe pain, as documented in the pain evaluation form. The resident's pain level was recorded as 9 out of 10, indicating very severe pain, yet the Treatment Administration Record showed that the medication was not given. The resident and his wife expressed their dissatisfaction with the lack of pain management, leading them to leave the facility against medical advice. Interviews with the Licensed Vocational Nurse and the Regional Nurse Consultant revealed that the facility did not have the hydrocodone readily available, although it was present in the facility's medication dispensing cabinet. The staff's failure to administer the prescribed pain medication as ordered contributed to the resident's prolonged pain and subsequent decision to leave the facility.
Failure to Update Staffing Sheets Timely
Penalty
Summary
The facility failed to update the staffing sheets at the beginning of each shift or in a timely manner to reflect the staff working that day. On multiple occasions, the posted staffing sheets were not updated to show the current staff, including the evening shift. Specifically, on 03/25/24, the staffing sheet was not in a clear and readable format and was not updated for the evening shift. This issue persisted on 03/26/24 and 03/27/24, where the sheets were not updated to reflect the current date. The facility's policy requires the posting of staffing information daily at the beginning of each shift, but this was not adhered to. During an interview, the DON and the Administrator confirmed that the staffing sheets should be completed and posted daily at the beginning of each shift.
Failure to Properly Date Insulin Pens and Separate Expired Supplies
Penalty
Summary
The facility failed to ensure that opened insulin flex pens and prefilled syringes were properly dated when initially opened by nursing staff. During an observation of medication cart 100, it was found that a Basagler flex pen and an Ozempic prefilled syringe did not have open dates written on them. Both medications were in use, and this was confirmed by an LPN and the Director of Nursing, who acknowledged that staff should have written the dates on all insulin pens. Additionally, the facility did not ensure that expired supplies were kept separate from unexpired supplies. An observation of the 100-medication cart revealed two open bottles of Assure Dose glucose control tests that did not have open dates written on them. These tests expire within 90 days of opening. An LPN confirmed that staff should have dated the two open bottles of Assure Dose with an open date.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety. Specifically, staff did not monitor the internal temperature of food to ensure it was safe for consumption. During an observation of the lunch meal trays, the dietary aide recorded the temperature of the pork chops at 129 degrees Fahrenheit, which is below the FDA Food Code requirement of 135 degrees Fahrenheit for hot foods. The Dietary Director confirmed that the food temperatures were not at an acceptable level. This deficiency could potentially affect all 56 residents who consume food prepared in the facility's kitchen.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection prevention measures during medication administration and the use of medical equipment. Specifically, staff did not sanitize their hands before or after administering medications to three residents. Additionally, staff did not sanitize the blood pressure cuff after using it on five residents. These actions were observed during medication administration rounds, where Licensed Practical Nurses (LPNs) were seen preparing and administering medications without following hand hygiene protocols and using the same blood pressure cuff on multiple residents without sanitizing it in between uses. The facility's Medication Administration policy and CDC guidelines were not adhered to, as confirmed by the Assistant Director of Nursing (ADON) during an interview. Furthermore, an oxygen cannula was found on the floor and subsequently placed into a resident's nose without being replaced or sanitized. This incident was observed when a Certified Nursing Assistant (CNA) picked up the cannula from the floor, placed it on another resident's bed, and then inserted it into the resident's nose. The LPN confirmed that the staff should have replaced the cannula with a new one after it had been on the floor and another person's bed. These deficiencies highlight significant lapses in infection control practices within the facility.
Non-Functional Kitchen Equipment
Penalty
Summary
The facility failed to ensure kitchen equipment was in safe operating condition. During an observation on 03/26/24 at 12:15 PM, one section of the steam table was found to be non-functional. The steam table light was off, the well dial was set to high, but the water in the steam well was cool to the touch, and there was no steam present. A pan of pork chops placed in the well measured 129 degrees Fahrenheit. On 03/25/24 at 1:30 PM, the Dietary Director confirmed the problems with the steam table.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that residents, resident representatives, and the Ombudsman received a written notice of transfer as soon as practicable. This deficiency was identified for one resident who was admitted to a hospital. The administration progress note and the Discharge Minimum Data Set (MDS) indicated that the resident had an unplanned discharge to a short-term general hospital. During an interview, the Director of Nursing (DON) confirmed that there was no documentation showing that the Ombudsman was notified of the resident's transfer from the facility.
Failure to Maintain Records of Controlled Substances
Penalty
Summary
The facility failed to maintain records of controlled substances on each medication cart, as observed on multiple occasions. Specifically, staff did not sign the narcotic book to show they counted the medication blister pill cards and compared them to the residents' medication sheets for numerous dates between 3/11/24 to 03/19/24. This was observed on the 200 medication cart on 03/24/24 at 4:05 pm. During an interview on 03/25/24 at 4:06 pm, a Certified Medication Aide (CMA) confirmed that there were missing signatures from the narcotic book. The CMA stated that they counted the narcotics at the beginning and end of each shift but failed to document this in the narcotic book. The Director of Nursing (DON) also confirmed during an interview on 03/25/24 at 4:45 pm that the nursing staff should sign the narcotic book when they come onto and go off each shift to ensure the narcotic count is correct before the oncoming shift nurse takes the keys for the narcotic box from the off-going shift nurse.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure they monitored for side effects of medication for two residents, leading to a deficiency in medication management. Resident #56 had a physician's order for clopidogrel bisulfate and enoxaparin sodium, but staff did not document monitoring for the anticoagulant in February and March 2024. Similarly, Resident #111 had physician's orders for enoxaparin sodium and insulin lispro, but staff failed to document monitoring for the anticoagulant and blood sugar levels in both February and March 2024. During an interview, the Director of Nursing confirmed that staff should monitor and document residents on insulin and anticoagulants. However, the DON acknowledged that staff did not document monitoring for Resident #111's anticoagulants, hyperglycemia, and hypoglycemia, nor did they monitor Resident #56 for the anticoagulant. This lack of documentation and monitoring could lead to adverse outcomes for the residents involved.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for two residents. For the first resident, the quarterly MDS indicated the resident was taking an anticoagulant, but the Electronic Health Record (EHR) showed no physician's order for such medication since the resident's admission. The MDS Coordinator confirmed this was an error during an interview, acknowledging that the resident had not been prescribed an anticoagulant. For the second resident, the psychiatric physician notes indicated a diagnosis of schizoaffective disorder, and the care plan noted the use of psychotropic medication. However, the quarterly MDS did not reflect the resident's psychotic disorder. The MDS Coordinator stated she was unaware of the diagnosis and would typically consult with the physician to correct any inaccuracies. This oversight resulted in the MDS not accurately representing the resident's psychiatric condition.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented within 21 days of readmission for a resident. Record review revealed that the care plan, dated 03/22/24, had all items marked as resolved or cancelled. During an interview on 03/29/24, the MDS Coordinator stated she did not know why the staff marked all items in the care plan as resolved or cancelled, and confirmed that all items should still be effective as they were still pertinent to the resident.
Failure to Update Diagnosis and Follow Liquid Consistency Orders
Penalty
Summary
The facility failed to provide services that meet professional standards when staff did not update the diagnosis for the use of a medication ordered for a resident and did not follow the physician's order regarding liquid consistencies for another resident. Specifically, a resident was admitted with a diagnosis of anxiety and had an order for alprazolam to be administered via PEG tube for insomnia and anxiety. However, the face sheet was not updated to include the diagnosis of insomnia, despite the medication being administered daily for both conditions. This discrepancy was confirmed during an interview with the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator. Additionally, another resident had a diet order for mechanical soft texture and mildly thick consistency liquids. Despite this, the Administrator served the resident two cups of cranberry juice that were thin liquids, contrary to the physician's order. The DON confirmed that staff should have served thickened liquids and should have notified the physician for approval of any dietary changes, which was not done on that day.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure a resident received necessary dental services. During an interview, the resident stated her top dentures were missing and she had informed the facility's administrator, although she could not recall when. An observation confirmed the resident had several missing teeth and was not wearing dentures. The resident's care plan indicated she had upper and lower dentures and was at risk for difficulty chewing, malnutrition, and dehydration. A dental note from a few months prior indicated a follow-up appointment was needed for upper dentures, but the Social Services Director confirmed that the resident had not attended this follow-up appointment.
Failure to Provide Properly Thickened Liquids for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with dysphagia received food and drink prepared in a form designed to meet their individual needs. The resident had a diagnosis of dysphagia and required extremely thick, pudding-like drink consistency. However, during multiple observations, the resident was given drinks that were not properly thickened, leading to difficulty swallowing and coughing. The Occupational Therapy Director and Minimum Data Set Director had to intervene by adding thickener to the resident's drink after noticing the inconsistency. The resident's medical record, care plan, and physician orders did not include the necessary information regarding the required thickened liquids. The care plan and orders were not coordinated with the meal ticket, resulting in the resident receiving inappropriate drink consistency. This lack of coordination and documentation led to the resident experiencing difficulty swallowing and potential choking hazards during mealtimes.
Failure to Ensure COVID-19 Vaccination Offer and Documentation
Penalty
Summary
The facility failed to ensure staff offered COVID-19 vaccinations to three out of five residents reviewed for COVID-19 vaccines. For one resident, the Electronic Health Record (EHR) did not show that the staff offered the COVID-19 vaccination, and the Director of Nursing (DON) could not provide documentation of the resident's declination, despite the resident stating she did not decline the vaccine. Another resident received the first dose of the COVID-19 vaccine, but the EHR did not indicate that the second dose was administered, which the DON and Infection Preventionist (IP) confirmed. A third resident received a COVID-19 vaccine but there was no documentation to show that staff offered subsequent doses after the initial vaccination.
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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