Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manzano Del Sol By Purehealth during CMS and state inspections, most recent first.
A required Five-Day Report detailing the results of an abuse investigation was not submitted to the State Survey Agency after an incident involving a resident. Although the initial incident report was sent, facility records and administrator interview confirmed the follow-up report was missing.
A resident with osteoporosis, anemia, TIA, and a history of falls received duplicate clopidogrel/Plavix orders after an NP entered a second order to change the administration time but did not discontinue the original order. Nursing staff confirmed the new order without reviewing the resident’s current meds, and the MAR showed both doses were given daily for 19 consecutive days. Staff acknowledged that an extra dose of Plavix could cause bleeding.
The facility failed to ensure the MD participated in QAPI, IPCP, and the MRR program. An NP reviewed monthly MRRs and acted on the pharmacist’s recommendations without consulting the Attending Physician, who stated he did not review or act on the MRRs. The Administrator expected the MD to review the MRRs or direct the Attending Physician to do so, and the MD stated she should have provided oversight of the MRR process.
The facility failed to ensure the MD participated in required QAPI/QAA committee meetings. The QAPI policy and plan identified the MD as a standing member expected to attend monthly meetings, but roster review showed no attendance since September 2024. The NP stated she never saw the MD attend a QAPI meeting, and the Administrator confirmed the MD had not attended any monthly or quarterly QAPI meetings despite calendar invites being sent.
Medical Director Did Not Participate in Infection Control Program: The facility failed to ensure the MD attended scheduled infection control meetings or participated in the IPCP. Record review showed the MD did not attend multiple infection control meetings, and the ICP stated he had not met the MD at any of the meetings and did not communicate with the MD or attending physician about IPCP issues. The Administrator stated the MD was expected to be part of the IPCP, but the MD did not respond to interview requests.
Hazardous bleach disinfectant wipes were left on a banister in a common area with residents nearby and no staff present. The residents involved had dementia and significant cognitive impairment, including impaired judgment, memory, safety awareness, and hazard recognition. CNA, RN, DON, and the Administrator all stated the wipes should not be left out because residents could use them improperly, including on their faces or in their mouths.
Failure to Provide Routine and Emergency Dental Services: Two residents did not receive timely dental follow-up. One resident with CKD and DM reported not having a dental visit in a long time, and staff acknowledged a missed rescheduling after a hospital stay. Another resident with severe cognitive impairment and reported mouth pain had no documented dental referral, assessment, or appointment, and an RN confirmed the pain was not documented.
A resident with multiple medical conditions experienced two falls shortly after admission, resulting in a right femoral neck fracture and subsequent hospitalization. The facility did not conduct an investigation into the falls or the injury, and the DON did not submit the required Five Day Follow-Up report to the State Agency.
Failure to Assist Resident With Grooming Services: A resident with assistance with personal care and MDD was observed with multicolored, uneven hair and stated she had not had a haircut in two years. She reported being embarrassed by her appearance, wanted help arranging beautician services, and said multiple calls to the facility beautician were not returned. The resident also stated she was told wheelchair users could not receive beautician services, despite facility records noting Social Services involvement with beautician scheduling.
Inconsistent advance directive and code status documentation was found for a resident. The chart showed Full Code on the face sheet and in care conference documentation, while a MOST form in the nurses’ station binder listed DNR with comfort measures and no hospital transfer unless comfort needs could not be met. The care plan did not include an advance directive, and the resident, an LPN, and the Administrator all described conflicting code status information in the record.
A resident with weakness, unsteadiness, cognitive communication deficit, need for assistance with personal care, and a left femur fracture had a PRN alprazolam order for anxiety left with an indefinite stop date. The PC recommended a 14-day limit for the psychotropic medication, but the AP did not respond, and the DON and AP stated they expected or were unaware of the required 14-day stop date for PRN psychotropic orders.
The facility failed to ensure accurate MDS coding for two residents. One resident with Alzheimer's disease had an annual MDS that stated no natural teeth and dependence for oral hygiene, but observation and notes showed missing and broken teeth and the DON acknowledged tooth problems. Another resident with dysphagia, hemiplegia, and stroke-related communication issues was coded as having clear speech, even though the care plan, observations, staff interviews, and progress notes documented the resident as nonverbal and communicating only by gestures or a communication board.
A resident admitted with muscle weakness, unsteady gait, cognitive communication deficit, and need for help with personal care did not have a baseline care plan completed within the required 48-hour timeframe. The UM stated weekend admissions were handled on the next business day and floor nurses were not expected to do care plans, while the DON stated nursing leadership handled care plans and was unaware that weekends counted in the 48-hour window.
Failure to Care Plan Oral Hygiene and Dental Services: A resident with Alzheimer's disease and A-Fib had documented tooth problems, severe cognitive impairment, and missing front teeth, yet the care plan did not address oral care or dental services. The Administrator stated the resident had not received dental services since admission, while the DON said oral hygiene care planning was only needed if there was an oral infection or other oral cavity issue.
Failure to Address CP Medication Review Recommendation: A resident with weakness, unsteadiness, cognitive communication deficit, and a left femur fracture had an active PRN alprazolam order with an indefinite stop date. The CP’s MRR recommended limiting the alprazolam to a 14-day duration, but the AP did not respond to the recommendation and stated he was unaware PRN psychotropic orders needed a 14-day stop date.
Resident Refrigerator Sanitation and Food Labeling Deficiency: The facility failed to keep the 200-unit resident refrigerator clean and sanitary and failed to label food items with a resident name. During observation, the refrigerator interior was grimy, sticky, and had brown fluid pooled on the bottom under the clear drawers, and several unopened food and drink items were found without resident labels. The Unit Mgr and Administrator stated the refrigerator should be clean and all items should be labeled.
A facility failed to accurately complete the MDS Assessment for a resident, incorrectly documenting the absence of pressure ulcers at both admission and discharge. Despite progress notes indicating a pressure ulcer on the coccyx at admission and a stage 3 pressure ulcer at discharge, the MDS was not updated to reflect these conditions. The DON confirmed the inaccuracies in the MDS coding.
A resident with multiple health issues experienced a significant decline in nutritional intake and weight loss, which the facility staff failed to recognize as a change in condition. Despite worsening symptoms, including pocketing food and drink, elevated heart rate, and low oxygen saturation, the staff delayed sending the resident to the hospital for two days. The resident was eventually hospitalized with dehydration, urinary tract infection, and sepsis, highlighting the facility's inadequate monitoring and delayed response.
The facility failed to prevent accidents and ensure safe transfers, leading to multiple incidents where residents fell due to unlocked beds, improper use of Hoyer lifts, and lack of supervision during transfers. Staff did not adhere to care plans and proper procedures, resulting in falls and potential injuries.
The facility failed to ensure expired supplies were separated from unexpired ones and did not consistently document medication refrigerator temperatures. An expired Medstream dressing change kit was found stored with non-expired supplies, and temperature logs for the medication refrigerator were incomplete, risking the potency and effectiveness of stored medications.
A resident with multiple contractures did not receive a restorative nursing program after rehabilitation services ended. The resident's care plan aimed to improve her range of motion, but no restorative therapy was provided, leading to her being found in a fetal position and unable to get out of bed. The Director of Rehabilitation confirmed the lack of therapy and stated that the resident would benefit from a restorative program.
Failure to Submit Required Five-Day Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit a required Five-Day Report to the State Survey Agency following an allegation of resident-to-resident abuse. Record review showed that while the initial incident report was submitted to the State Survey Agency, there was no documentation indicating that the follow-up Five-Day Report, which includes the results of the facility's investigation, was ever sent. During an interview, the Administrator confirmed the absence of the Five-Day Report for the incident and stated that it was expected to be submitted within the required timeframe.
Duplicate Plavix Order Led to Significant Medication Error
Penalty
Summary
The facility failed to keep a resident free from a significant medication error when a duplicate order for clopidogrel/Plavix was entered and both orders remained active. The resident had diagnoses including osteoporosis with left femur fracture, history of falling, anemia, and TIA. One active order for clopidogrel 75 mg by mouth every morning for cardiac health was already in place when a second active order for Plavix 75 mg by mouth at bedtime for A-fib was entered by the NP, and the original order was not discontinued. Medication administration records showed the resident received both clopidogrel and Plavix every day for 19 consecutive days. Nursing staff confirmed the new Plavix order without reviewing the resident’s current medication list, and the DON stated that reviewing current medications was not part of the confirmation process. The NP stated she entered the new order to change the administration time to the evening medication pass but did not stop the original order. The resident stated she was not aware she received a double dose of Plavix and reported she had always received Plavix once daily before admission. During interviews, staff acknowledged that giving an extra dose of Plavix could cause bleeding. The report states the duplicate order created an Immediate Jeopardy on the date the second order was entered. The resident had no reported side effects at the time of the later assessment, and lab work showed CBC and platelets within normal limits, but the deficiency occurred because the duplicate antiplatelet orders were active and administered concurrently for nearly three weeks.
Medical Director Did Not Oversee MRR Process
Penalty
Summary
The facility failed to ensure the Medical Director participated in the QAPI, IPCP, and MRR programs. During an interview, the Nurse Practitioner stated she reviewed the facility’s monthly MRRs and responded to the pharmacist’s recommendations without consulting the Attending Physician. The Attending Physician later stated he did not review or act on the monthly MRRs and that the Nurse Practitioner handled them. The Administrator stated she expected the Medical Director to review the monthly MRRs or direct the Attending Physician to review them. The Medical Director stated she expected the Attending Physician to review the MRRs, acknowledged she should have provided oversight of the MRR process, and stated she should have instructed the Attending Physician to review the MRRs instead of the Nurse Practitioner.
MD Did Not Participate in Required QAPI/QAA Meetings
Penalty
Summary
The facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement/Quality Assurance and Assessment (QAPI/QAA) Committee meetings as required by regulation. The facility’s QAPI Program policy, revised September 2024, stated the QAPI/QAA Committee met monthly and included the Administrator, DON, Medical Director, and at least three other staff members from different disciplines. The facility’s QAPI plan, dated January 2025, identified the MD as a standing committee member with responsibility for participating in monthly meetings. Record review of the QAPI/QAA committee rosters showed the MD did not attend any QAPI meetings since September 2024. During an interview on 08/07/2025, the NP stated she never saw the MD attend a QAPI meeting. During an interview on 08/11/2025, the Administrator stated the last time the MD attended a QAPI meeting was in September 2024 and that the MD did not attend any monthly or quarterly QAPI meetings since then, despite calendar invites being sent to staff for the monthly and quarterly meetings. Phone calls were made to the MD on 08/06/25, 08/14/25, and 08/15/25 for an interview, but the MD did not respond.
Medical Director Did Not Participate in Infection Control Program
Penalty
Summary
The facility failed to ensure an effective Infection Prevention and Control program when the Medical Director did not attend any of the scheduled infection control monthly meetings and was not part of the program as expected by facility leadership. Record review of the Infection Control Online Meeting Invitations showed the MD did not participate in meetings held on 01/28/25, 02/04/25, 02/25/25, 03/25/25, 04/22/25, 05/27/25, and 07/16/25. During an interview on 08/08/25, the Infection Control Preventionist stated he had worked at the facility for nine months, had not met the MD at any infection control meetings, was not aware the MD was part of the IPCP, and did not communicate with the MD or attending physician regarding IPCP issues. The Administrator stated on 08/08/25 that she expected the MD to attend the infection control meetings and be part of the IPCP. Attempts to interview the MD by phone on 08/06/25, 08/14/25, and 08/15/25 were unsuccessful because the MD did not respond.
Hazardous bleach wipes left accessible to cognitively impaired residents
Penalty
Summary
The facility failed to ensure hazardous chemicals were stored securely and inaccessible to residents. The facility’s Hazardous Areas, Devices and Equipment policy stated that hazardous areas included access to toxic chemicals, that any element of the resident environment with the potential to cause injury and accessible to a vulnerable resident was considered hazardous, and that measures such as locks, alarms, and supervision would be used to keep hazardous areas and items inaccessible to vulnerable residents. Despite this, on 08/08/25 at 1:41 PM, a container of bleach disinfectant wipes was observed sitting on a banister in the common area with four residents nearby and no staff present. On 08/11/25 at 1:21 PM, bleach disinfectant wipes were again observed on a banister in the common area with two of the same residents nearby and no staff present. The residents involved had significant cognitive impairment. R #55 had dementia with cognitive impairment affecting decision-making, memory, and safety awareness, and a BIMS score of 8, indicating moderate impairment. R #13 had unspecified dementia with severe cognitive impairment affecting judgment, understanding, and communication and required extensive assistance with all activities of daily living. R #41 had vascular dementia with impaired decision-making and hazard recognition, and R #46 had Alzheimer’s disease and vascular dementia with severe cognitive impairment. CNA #1, RN #2, the DON, and the Administrator all stated the wipes should not be left out, and the DON and Administrator stated residents could use the wipes improperly or as wet wipes, including putting them in their mouths or using them on their faces or in the restroom.
Failure to Provide Routine and Emergency Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services for 2 residents. One resident was admitted with stage 3 chronic kidney disease and type 2 diabetes and stated she had not had a dental appointment in a long time, although she believed she was supposed to have dental visits every 6 months because she was on dialysis. Social Services stated she did not make appointments, and the Patient Access Representative/Appointment Scheduler stated she had the resident on her list for a dental appointment but had not rescheduled it after the resident went to the hospital when the last appointment was due. The resident’s care plan dated 12/31/24 showed an oral/dental health problem that was initiated and resolved on the same date, with no current active dental or oral health problems or interventions documented. Another resident, admitted in 2008 with hemiplegia and hemiparesis, diabetes mellitus, and depression, had severe cognitive impairment with a BIMS score of 3. The resident pointed to his front teeth and stated they hurt, but the progress notes did not contain documentation of a dental referral, assessment, or appointment related to the reported oral pain. An RN stated he heard the resident say his mouth hurt but did not document the pain in the progress notes. The Administrator stated staff did not make a dental appointment after the complaint of mouth pain and that the resident’s record did not show a dental appointment.
Failure to Submit Required Five Day Report After Resident Falls and Injury
Penalty
Summary
The facility failed to complete and submit a Five Day Report to the State Agency following allegations of neglect involving a resident who experienced multiple falls and sustained a right femoral neck fracture. The resident, who had diagnoses including cardiomyopathy, type 2 diabetes mellitus, unspecified dementia, hypoxemia, and atherosclerotic heart disease, was admitted and subsequently fell twice shortly after admission. The falls were documented in the Facility Reported Incident, but the times of the falls were not recorded. The resident complained of pain, which led to the diagnosis of a right femoral neck fracture, and was then discharged to the hospital. A review of the resident's electronic health record revealed no evidence that the facility conducted an investigation into the falls or the resulting fracture. During an interview, the DON stated that no investigation was completed because the resident did not return to the facility after hospitalization. The DON acknowledged awareness of the requirement to submit a Five Day Follow-Up report to the State Agency but did not do so in this case.
Failure to Assist Resident With Grooming Services
Penalty
Summary
The facility failed to ensure a resident maintained a dignified existence when staff did not assist with arranging grooming services for a resident with assistance with personal care and major depressive disorder. The facility’s Resident Rights policy stated residents had a right to privacy, dignity, and self-determination, and the Dignity Policy stated residents were to be cared for in a manner that promoted well-being and self-worth and were to be groomed as they wished, including hair styles, nails, and facial hair. The resident’s record showed care conference notes indicating Social Services would provide a schedule and contact information for the facility’s contracted beautician and later would contact the beautician. During interview, the resident stated she had not received a haircut in two years, wanted help arranging beautician services, and said having her hair colored and cut would make her feel better. She stated her hair was a mess, she was embarrassed by her appearance, and she had called the facility’s beautician multiple times without a return call. She also stated she was told the beautician did not provide services to residents in wheelchairs and that only residents who could walk, sit in the chair, and sign themselves up or have a family member assist received beautician services. Observation showed her hair was multicolored with grown-out dye and uneven lengths.
Inconsistent Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident’s current advance directive and code status were properly documented and consistent across the record for one resident. The resident’s Face Sheet listed the resident as Full Code on admission, while a MOST form dated 04/18/2024 documented DNR, comfort measures, no hospital transfer unless comfort needs could not be met in the current location, and use of medication, positioning, wound care, and other measures to relieve pain and suffering. A progress note dated 08/03/25 also documented conflicting information, stating the resident’s code status was attempt Full Code while also listing comfort measures and instructions not to transfer to the hospital unless comfort needs could not be met in the current location. The resident’s Care Plan dated 12/27/24 did not include an advance directive, and the Care Conference dated 01/15/25 documented the resident’s code status as Full Code. During interview, the resident stated his code status was full code and that he wanted resuscitation with comfort measures to relieve pain. An LPN stated the physician orders indicated Full Code, while the MOST form in the nurses’ station binder indicated DNR, and the Administrator stated the resident’s code status was Full Code while the MOST form indicated DNR. The Administrator also stated the most recent care plan did not document an advance directive and that advanced directives were expected to be accurate and honored.
PRN Alprazolam Order Left Indefinite Without Required 14-Day Limit
Penalty
Summary
The facility failed to ensure that a resident did not receive a psychotropic medication unless it was medically necessary when the resident’s PRN alprazolam order was left with an indefinite stop date instead of being limited to 14 days or supported by documentation to extend beyond 14 days. The report identified this as a deficiency for 1 resident, who was admitted with muscle weakness, unsteadiness on feet, cognitive communication deficit, need for assistance with personal care, and a displaced intertrochanteric fracture of the left femur. Record review showed the resident had an active order for alprazolam 0.25 mg by mouth every 24 hours PRN for anxiety with an indefinite stop date. The consultant pharmacist reviewed the medication regimen and recommended limiting alprazolam to a 14-day duration, but the attending physician did not respond to the recommendation. During interviews, the DON stated she expected the attending physician to enter a 14-day stop date for the psychotropic medication order, and the attending physician stated he was not aware PRN psychotropic medication orders needed a 14-day stop date.
Inaccurate MDS Coding for Oral Status and Communication Ability
Penalty
Summary
The facility failed to ensure the MDS was accurate for two residents. For one resident with a history of Alzheimer's disease and atrial fibrillation, the annual MDS stated the resident was dependent on staff for oral hygiene and did not have natural teeth. However, observation showed missing and broken teeth, the care plan did not include oral care, and a progress note documented that the DON noted problems with the resident's teeth. During interview, the DON stated the resident had natural teeth and said the annual MDS was coded correctly, while also stating she was responsible for review and accuracy of the MDS. For another resident with dysphagia, hemiplegia, and cerebral infarction, the annual MDS stated the resident had clear speech. In contrast, the care plan described communication problems, use of a communication board, and nonverbal communication; observation showed the resident was nonverbal; staff interviews confirmed the resident was nonverbal; and multiple progress notes and a social services assessment documented nonverbal status, aphasia, and communication by gestures. The DON later stated the resident was nonverbal and that the annual MDS was incorrectly coded because staff should have coded that the resident did not speak.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for one resident. The resident was admitted with muscle weakness, unsteadiness on feet, cognitive communication deficit, and need for assistance with personal care. Record review showed the resident’s baseline care plan was not developed by the 48-hour deadline and was instead dated the following day. Facility interviews showed the Unit Manager stated that residents admitted late Friday or over the weekend would have baseline care plans completed on the following business day, and that floor nurses were not expected to complete care plans. The Unit Manager also stated she could not provide a reason why the resident’s baseline care plan was not completed within 48 hours. The DON stated nursing leadership was responsible for baseline and comprehensive care plans, that weekend staff were not expected to cover Friday admissions, and that she did not know when the 48-hour timeframe started or that weekends counted toward the timeframe.
Failure to Care Plan Oral Hygiene and Dental Services
Penalty
Summary
The facility failed to develop and implement resident-focused, comprehensive care plans to address the oral hygiene needs of one resident with Alzheimer's disease and atrial fibrillation. Record review showed the resident was admitted on 06/14/2023, and progress notes documented disorganized thinking and severe cognitive impairment on 04/08/25. On 02/25/25, the resident had problems with their teeth, and on 08/09/25 the resident was observed with missing front teeth. The resident's care plan, dated 06/23/2023, did not address dental services or oral care. During interview, the Administrator stated the resident had not received dental services since admission and said it was her expectation that oral care be care planned so the resident could receive routine dental services. The DON stated residents did not require a care plan for dental services or oral hygiene unless they had an infection or other oral cavity issue, and confirmed that R #6 did not have a plan for dental services or oral hygiene anywhere in the care plan.
Failure to Address Consultant Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to ensure pharmaceutical services were met for one resident reviewed for unnecessary medications when the Attending Physician and Medical Director did not review, respond to, or act on the Consultant Pharmacist’s identified irregularities sent through the monthly Medication Regimen Review process. Facility policy stated the Consultant Pharmacist should use monthly and interim drug regimen reviews to identify potentially problematic medications, including regimens not supported by clinical signs or symptoms, and should review each resident’s medication regimen and clinical record at least monthly. The resident was admitted with diagnoses including muscle weakness, unsteadiness on feet, cognitive communication deficit, need for assistance with personal care, and a displaced intertrochanteric fracture of the left femur. The resident had an active order for alprazolam 0.25 mg by mouth every 24 hours as needed for anxiety with an indefinite stop date. The Consultant Pharmacist’s monthly review recommended limiting alprazolam to a 14-day duration, but the Attending Physician did not respond to that recommendation. During interview, the Attending Physician stated he reviewed the resident’s medications monthly and was not aware that PRN psychotropic medication orders needed a 14-day stop date, and the Consultant Pharmacist stated he expected the Attending Physician to enter a 14-day stop date for the alprazolam order.
Resident Refrigerator Sanitation and Food Labeling Deficiency
Penalty
Summary
The facility failed to ensure resident refrigerators were maintained in a clean and sanitary condition and failed to label and date food items stored in the refrigerators. Record review of the facility policy titled Food Storage and Sanitation, revised April 2024, stated that all food items stored in resident refrigerators were to be labeled and dated upon placement, refrigerators were to be cleaned on a scheduled basis and kept free of spills, grime, and food residue, and staff were responsible for monitoring food storage and appliances to remain sanitary and safe for resident use. During observation of the 200-unit resident refrigerators in the common area, the interior was found to be grimy, sticky, and had brown fluid pooled on the bottom under the clear drawers. The observation also identified an unopened can of V8 juice, two Sprite zeros, and eight unopened pudding packs that were not labeled with a resident's name. During interviews, the Unit Manager stated the refrigerators should be cleaned and all food should be labeled with the resident name, and the Administrator stated it was her expectation that all items in the resident refrigerators be labeled with the resident's name and that the refrigerator be clean and free from dirt or spills.
Inaccurate MDS Assessment for Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate and comprehensive Minimum Data Set (MDS) Assessment for a resident, which is a federally mandated assessment instrument. Upon admission, the resident was documented as having no pressure ulcers, despite progress notes indicating the presence of a pressure ulcer on the coccyx measuring 2 cm by 1.4 cm by 0.2 cm. At discharge, the resident's MDS Assessment again inaccurately indicated no pressure ulcers, even though progress notes documented a stage 3 pressure ulcer. The Director of Nursing confirmed that the resident had a pressure ulcer at both admission and discharge, and acknowledged that the MDS was incorrectly coded.
Failure to Address Resident's Decline Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate care for a resident who was admitted with multiple diagnoses, including fetal alcohol syndrome, severe intellectual disabilities, urinary tract infection, urinary retention, and dysphagia. The staff did not recognize the resident's decrease in nutritional intake and significant weight loss as a change in condition. Despite the resident's declining health, including a significant weight loss of 13 pounds in a week and a decrease in supplement intake, the staff did not take timely action to address these issues. The resident's condition worsened with symptoms such as pocketing food and drink, elevated heart rate, low oxygen saturation, and fever. Despite these alarming signs, the staff delayed sending the resident to the hospital for two days. The resident was eventually admitted to the hospital with dehydration, urinary tract infection, and sepsis. Interviews with staff and the resident's guardian revealed inconsistencies in communication regarding the resident's condition and care, contributing to the delay in appropriate medical intervention. The facility's staff, including the nurse practitioner and director of nursing, acknowledged the resident's decline but failed to act promptly. The resident's guardian and hospital staff expressed concerns about the resident's malnourishment and dehydration upon hospital admission. The facility's lack of timely response and inadequate monitoring of the resident's condition likely contributed to the resident's severe health deterioration.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to prevent accidents and provide safe transfers for residents, leading to multiple incidents. One resident, admitted with multiple diagnoses including hypotension, anemia, depression, and malnutrition, fell out of bed because the bed was not locked. Staff interviews confirmed that the bed was often moved for various reasons but was not relocked, which led to the resident falling while reaching for water. The facility's care plan for this resident indicated that the bed should always be locked, but this was not adhered to, resulting in the fall and subsequent injury to the resident. Another resident, who was totally dependent on staff for assistance and required a Hoyer lift for transfers, fell when the lift tipped over during a transfer. The incident report revealed that the CNAs assisting the resident did not use the Hoyer lift correctly, causing it to tip and graze the resident's head. The DON confirmed that improper use of the Hoyer lift was the cause of the incident. Despite attending in-service training on the proper usage of Hoyer lifts, the staff failed to follow correct procedures, leading to the resident's fall. Additionally, a resident who required supervision during transfers fell while transferring from a wheelchair to a shower chair because the wheelchair brakes were not locked. The resident and a CNA were present during the incident, but the CNA did not ensure the brakes were locked, resulting in the resident sliding out of the wheelchair. The Director of Rehabilitation confirmed that the CNA should have either reminded the resident to lock the brakes or locked them herself. Another resident also experienced a fall during a transfer with a Hoyer lift, which tipped over due to incorrect use by the staff, as confirmed by the DON and the incident report.
Failure to Manage Expired Supplies and Document Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that expired supplies were not kept with unexpired supplies and that staff documented the medication refrigerator temperatures. During an observation of the 100 hall medication room, a Medstream dressing change kit was found to be expired and stored with non-expired supplies. A medication technician confirmed the supplies were expired and stated that nursing staff were expected to periodically check and remove expired or soon-to-expire supplies. This oversight could result in the use of expired supplies on residents, potentially compromising their care. Additionally, a review of the 100 hall medication room's refrigerator temperature logs revealed that staff did not document the temperatures on multiple occasions. Insulin and other medications requiring refrigeration were stored in the refrigerator, which had both an analog temperature gauge and a digital temperature sensor. The Director of Nursing confirmed that staff were required to check and document refrigerator temperatures daily to ensure they remained within the appropriate range of 36 to 46 degrees Fahrenheit. The failure to document these temperatures could affect the potency and effectiveness of the medications stored within.
Failure to Provide Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent a decrease in range of motion and mobility. The resident, who had multiple contractures in the left shoulder, left lower leg, left ankle and foot, left elbow, and right foot and ankle, was not provided with a restorative nursing program after rehabilitation therapy services ended. The resident's care plan aimed to improve her range of motion and functional abilities, but no restorative therapy was provided after the cessation of rehabilitation services. During an observation, the resident was found lying in bed in a fetal position, unable to get out of bed. The Director of Rehabilitation confirmed that the resident had not received any physical, occupational, or restorative therapy since the rehabilitation services ended. The Director also stated that the resident would benefit from a restorative nursing program to prevent further worsening of her contractures and possibly improve her condition.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 271 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Albuquerque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Princeton Health & Rehabilitation | 1.1 mi | ★★★★★ | 8 | 0 |
| Uptown Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Advanced Health Care Of Albuquerque | 2.1 mi | ★★★★★ | 0 | 0 |
| Odelia Healthcare | 2.5 mi | ★★★★★ | 3 | 0 |
| Sandia Ridge Center | 2.7 mi | ★★★★★ | 11 | 0 |
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