Northgate Unit Of Lakeview Christian Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlsbad, New Mexico.
- Location
- 1905 West Pierce Street, Carlsbad, New Mexico 88220
- CMS Provider Number
- 325087
- Inspections on file
- 17
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Northgate Unit Of Lakeview Christian Home during CMS and state inspections, most recent first.
A paper listing residents' names and vital sign readings was left face up on the nurses station countertop, exposing personal health information to unauthorized individuals. This was confirmed by a staff member and the DON, and had the potential to affect all residents on two halls.
A resident with a history of dizziness, dementia, and osteoporosis experienced an unwitnessed fall, which was documented in progress notes and led to new physician orders for fall prevention and monitoring. However, the annual MDS assessment failed to record the fall, and the MDS Coordinator confirmed the inaccuracy during an interview.
Two dietary aides were observed working in the kitchen without wearing hairnets, as required by facility policy. The Assistant Dietary Manager confirmed that all staff should have been wearing hairnets while in the kitchen. This lapse in food safety protocol had the potential to affect all residents in the facility.
Two residents did not have accurate or complete care plans regarding their need for supplemental oxygen. One resident's care plan incorrectly listed oxygen therapy despite no current order or use, while another resident who depended on supplemental oxygen had no care plan addressing this therapy. The DON confirmed these discrepancies during interviews.
Staff did not update care plans for two residents after significant changes in their care needs. One resident using assist bars for bed mobility did not have this intervention reflected in the care plan, and another resident admitted to hospice care did not have hospice services addressed in the care plan. The DON confirmed both omissions.
A deficiency was identified when staff failed to accurately document a resident's diagnosis of major depressive disorder on the PASRR Level 1 Identification Screen. Although the resident's records listed major depressive disorder, staff marked on the PASRR that there was no mental illness, a mistake later confirmed by the DON.
A treatment cart was observed unlocked and unattended in a hallway, with no staff present in the area. Both a case manager and an RN confirmed the cart was not secured, potentially allowing unauthorized access to medical supplies and personal health information for residents in nearby rooms.
The facility failed to maintain sanitary food service conditions by not ensuring staff performed hand hygiene when distributing food trays and assisting multiple residents with eating and drinking. This deficiency was observed in the dining room and confirmed through staff interviews, potentially affecting all 76 residents.
The facility failed to implement a comprehensive antibiotic stewardship program, leading to improper monitoring and administration of antibiotics. A resident recovering from a UTI was prescribed ceftriaxone, but discrepancies in administration and discontinuation dates were found. The facility did not perform required antibiotic timeouts or involve the physician in daily discussions about antibiotic use.
The facility failed to ensure that two residents' bedside tables with frequently used items were within their reach, leaving them unable to access necessary items. Both residents were unable to get up on their own, and staff confirmed that the tables should have been positioned within reach.
The facility failed to provide written transfer notices to residents, their representatives, and the Ombudsman for six residents transferred to the hospital for various medical reasons. The Administrator confirmed the absence of a written transfer notice form, and the Ombudsman only received a monthly faxed list of transferred residents' names.
The facility failed to provide written notices of the bed hold policy to residents and their representatives during hospital transfers. The deficiency was identified for six residents, and the facility did not keep copies or document the notices in the medical records.
The facility failed to ensure care plan revision and care plan meeting requirements for multiple residents, leading to outdated care plans and lack of appropriate interventions. Notifications for care plan meetings were not effectively communicated, and hospice staff were often absent without documentation.
The facility failed to administer antibiotics in a timely manner for a resident with a positive urine culture and did not apply compression stockings as ordered for another resident with localized edema. The delay in starting antibiotics and the lack of adherence to the physician's order for compression stockings were confirmed through interviews and observations.
The facility failed to keep treatment carts locked when not supervised by staff and did not ensure a fall mat was placed next to a high fall-risk resident's bed as specified in the care plan. Multiple observations and staff interviews confirmed these deficiencies.
The facility failed to ensure that the physician provided a rationale for not following the pharmacist's recommendations for two residents reviewed for unnecessary medications. For one resident, the pharmacist recommended increasing the dosage of Metformin, which was denied without rationale. For another resident, the pharmacist recommended a reduction of either divalproex or Seroquel, but the provider marked the reduction as contraindicated without providing a rationale. This lack of documentation was confirmed by the DON.
The facility failed to initiate a GDR of medication as recommended by the pharmacist and ordered by the provider for two residents. One resident continued to receive the same dose of gabapentin despite a recommendation to reduce it, and another resident's provider did not document a rationale for not reducing divalproex or seroquel. The DON confirmed these deficiencies.
The facility failed to properly store medications and ensure medication carts were locked, affecting all 53 residents in the East and H Units. Unlocked medication carts and loose medications were observed, and insulin was improperly stored against manufacturer's instructions. These issues were confirmed by staff and the DON.
The facility failed to follow proper infection control practices by not labeling nasal cannulas with the date they were changed for three residents. This deficiency was confirmed through observations and staff interviews, indicating a lapse in the facility's protocol to change and date nasal cannulas weekly.
The facility failed to ensure call lights were functional and accessible in residents' bathrooms and bathing areas. Pull cords were not within reach from the floor for ten residents, and the alarm sound for call lights in two rooms was not working. Additionally, call lights were not within reach for two other residents. These issues were confirmed through observations and staff interviews.
The facility failed to provide required training on abuse, neglect, and exploitation (ANE) and Dementia Management to several staff members. The facility relies on face-to-face training sessions conducted monthly, but if a staff member misses a session, they may miss mandatory training. This was confirmed during interviews with the Administrator and the DON.
The facility failed to ensure the MDS was accurate for a resident who had a documented UTI. Despite the resident's symptoms and subsequent diagnosis, the quarterly MDS assessment did not reflect the UTI. The MDS Coordinator confirmed the inaccuracy during an interview.
The facility failed to provide a homelike environment for all 76 residents by not repairing broken roof tiles in the activity room. Observations revealed multiple broken and cracked tiles, and the Maintenance Director and Administrator confirmed the issues without specifying details of repairs.
Resident Health Information Left Unsecured at Nurses Station
Penalty
Summary
A deficiency occurred when a paper document containing residents' names and their vital sign readings was left face up on the nurses station countertop, making personal health information visible to unauthorized individuals. This was observed during a random facility check, and the presence of the document was confirmed by a staff member. The Director of Nursing also acknowledged that such information should be safeguarded and not left in plain view. The incident had the potential to affect all 38 residents residing on the East 1 and East 2 halls.
Inaccurate MDS Assessment Following Resident Fall
Penalty
Summary
Facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident's admission record included diagnoses of dizziness, senile dementia, and osteoporosis. On 03/18/25, the resident experienced an unwitnessed fall, which was documented in progress notes and resulted in new physician orders for fall prevention, monitoring for injuries, and neurological checks. Despite this incident, the resident's annual MDS assessment indicated that no falls had occurred since admission or the prior assessment. During an interview, the MDS Coordinator confirmed that the MDS was inaccurate because it did not reflect the documented fall.
Failure to Ensure Dietary Staff Wore Hairnets in Kitchen
Penalty
Summary
During an observation of the kitchen, it was noted that two dietary aides were not wearing hairnets while present in the kitchen area. This was confirmed during an interview with the Assistant Dietary Manager, who acknowledged that all staff are required to wear hairnets while in the kitchen. The failure to follow this protocol was observed during a random inspection and is likely to affect all 79 residents listed on the facility's census at the time.
Failure to Develop and Implement Accurate Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for two of four residents reviewed. For one resident, the care plan indicated a need for oxygen therapy, but current medical orders did not include supplemental oxygen, and the DON confirmed that the resident does not use oxygen, making the care plan inaccurate. For another resident, who was diagnosed with atherosclerotic heart disease, dementia, and dependence on supplemental oxygen, the care plan did not address the use of oxygen at all, despite the resident's ongoing need for it. The DON confirmed that this resident uses supplemental oxygen and should have a care plan in place for its use, but none was present.
Failure to Revise Care Plans for Assist Bar Use and Hospice Admission
Penalty
Summary
Staff failed to revise and update care plans for two residents following significant changes in their care needs. For one resident with multiple diagnoses including Parkinson's disease, abnormalities of gait, and polyosteoarthritis, an evaluation documented the use of bilateral assist bars for bed mobility and transfers, with the resident's consent. Despite the presence of assist bars on the bed and the resident's use of them for repositioning and mobility, the care plan did not include any reference to assist bar use. The Director of Nursing confirmed that the care plan was not updated to reflect this intervention. For another resident with a history of atherosclerotic heart disease, dementia, and hypertensive heart disease with heart failure, a medical order was issued to admit the resident to hospice care. However, the care plan, last updated several months after the hospice order, did not address hospice care or services. The Director of Nursing acknowledged that the resident was on hospice and that the care plan should have included this information, but it had not been updated accordingly.
Inaccurate PASRR Assessment for Resident with Major Depressive Disorder
Penalty
Summary
A deficiency occurred when the facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for a resident with a documented diagnosis of major depressive disorder. Record review showed that the resident was admitted with multiple diagnoses, including major depressive disorder, which is considered a mental illness. However, the PASRR Level 1 Identification Screen completed by staff indicated that the resident did not have a diagnosis or suspected mental illness. During an interview, the DON confirmed that the resident does have a diagnosis of major depressive disorder and acknowledged that the PASRR documentation was incorrect. This inaccuracy in the PASRR assessment was identified through both record review and staff interview, highlighting a failure to properly document the resident's mental health status as required.
Unattended Unlocked Treatment Cart Found in Facility Hallway
Penalty
Summary
Facility staff failed to ensure that all treatment carts were locked while unattended, as required for the secure storage of drugs and biologicals. During a random observation, a treatment cart located in the hallway of the 200 rooms was found unlocked with no facility employees present in the area. This was confirmed by both a case manager and a registered nurse, who acknowledged the cart was unlocked and subsequently secured it. The unlocked cart had the potential to allow unauthorized access to medical supplies and personal health information for all 18 individuals residing in rooms 200 through 216. No specific details about the medical history or condition of the affected residents were provided in the report.
Failure to Maintain Sanitary Food Service Conditions
Penalty
Summary
The facility failed to serve food under sanitary conditions by professional standards of food service safety, potentially affecting all 76 residents who eat food prepared in the kitchen. During an observation of the dining room of the H Unit, it was noted that a CNA did not wash or sanitize her hands with hand sanitizer in between meal passes. Additionally, in the main dining room, two staff members, a CNA and a Nurse Aide, assisted multiple residents with eating and drinking without performing hand hygiene between residents. This was confirmed by the staff members during interviews, where they admitted to not typically performing hand hygiene between feeding different residents. The Director of Nursing (DON) stated that staff do not need to perform hand hygiene when alternating between feeding two different residents unless a resident touches the item the staff member is using to feed the residents. This practice contradicts professional standards of food service safety and proper hand hygiene protocols, increasing the risk of foodborne illnesses among residents. The failure to adhere to these standards was observed and confirmed through staff interviews, highlighting a significant deficiency in the facility's food handling and hygiene practices.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. The facility's policy required nursing staff to conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response and review laboratory results. However, it was found that the facility did not follow this protocol. Specifically, the Director of Nursing (DON) confirmed that they do not perform 48-hour timeouts for antibiotics, and the Infection Preventionist (IP) stated that the physician is not involved in daily meetings discussing residents' antibiotic use and reactions. This lack of adherence to the policy has the potential to affect all 76 residents in the facility, as it could lead to inappropriate antibiotic use and resistance to multi-drug resistant organisms. The report highlighted the case of a resident recovering from a urinary tract infection (UTI). The resident was prescribed ceftriaxone, an antibiotic, which was administered as ordered. However, there were discrepancies in the administration and discontinuation dates of the antibiotic, indicating a lack of proper monitoring and communication. The resident's Medication Administration Record (MAR) showed that ceftriaxone was administered through specific dates, but there was no evidence of the required antibiotic timeout or consultation with the practitioner to determine if the antibiotic should continue or be adjusted. This failure to follow the antibiotic stewardship program's protocol underscores the facility's deficiency in managing antibiotic use effectively.
Failure to Provide Reasonable Accommodation of Resident Needs
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs for two residents, resulting in their bedside tables with frequently used items being out of reach. Resident #37 was observed sitting in a chair next to his bed with his call bell placed behind him on the bed, out of his sight and reach. Additionally, his bedside table with drinks was positioned approximately four feet away at the foot of his bed. Resident #37 confirmed that he was unable to get up on his own and could not access his drinks. This was corroborated by CNA #22, who acknowledged that the drinks should have been within the resident's reach. Similarly, Resident #41 was observed lying in bed with her bedside table, containing drinks and a box of tissues, placed about three feet away from her bed. Resident #41 stated that she was unable to get out of bed on her own and could not reach her drinks. CNA #23 and LPN #23 both confirmed that the bedside table with drinks and other frequently needed items should have been within Resident #41's reach. The Director of Nursing also confirmed that residents' bedside tables with frequently used items should be within their reach.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to ensure that residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for six residents reviewed for hospitalization. Specifically, residents were transferred to the hospital for various medical reasons, including falls, blood in stool, pain, MRSA, lethargy, and shortness of breath. In each case, the staff did not provide a written transfer notice to the residents or their representatives, nor did they send a copy of the written transfer notice to the Office of the State Ombudsman. This deficiency was confirmed through record reviews and interviews with the facility's Administrator and the Ombudsman. The Administrator confirmed that the facility does not have a written transfer notice form, and the Ombudsman confirmed that she only received a faxed list of resident names who were transferred to the hospital from the facility monthly, rather than copies of the written notices. This lack of proper documentation and notification could likely result in the residents and/or their representatives not knowing the reason or location of the resident's discharge, as well as the Ombudsman not being adequately informed to advocate for the residents effectively.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives received a written notice of the bed hold policy, which indicates the duration the bed would be held in cases of transfer to a hospital or therapeutic leave. This deficiency was identified for six residents who were transferred to the hospital for various medical reasons, including falls, blood in stool, pain, MRSA, lethargy, and shortness of breath. The medical records of these residents did not contain any written notice of the bed hold policy for their respective hospital transfers. During interviews, the Administrator and Receptionist confirmed that the facility's process involved sending bed hold notices by mail to the resident's representative the next business day. However, the facility did not provide the bed hold notice to the residents themselves, did not keep a copy of the notice, and did not document in the medical record that the notice was sent. This lack of documentation and direct communication with the residents led to the deficiency, as there was no evidence that the bed hold policy was communicated effectively to the residents or their representatives.
Care Plan Revision and Meeting Deficiencies
Penalty
Summary
The facility failed to ensure care plan revision and care plan meeting requirements for multiple residents. Specifically, the facility did not have the required Interdisciplinary Team (IDT) members and resident representatives participate in care plan meetings for two residents. Additionally, care plan meetings were not held within seven days after the completion of the MDS assessment for one resident. This led to the care plans not being updated with the most current resident conditions and appropriate interventions. The facility also failed to revise care plans with the most current resident information for several residents. For instance, one resident's care plan was not updated to reflect their fluctuating abilities, another resident's care plan did not include a recent urinary tract infection (UTI) diagnosis, and another resident's care plan did not account for a recent hospitalization due to a gastrointestinal bleed. Furthermore, the care plans for some residents did not include necessary medical interventions such as compression stockings and oxygen therapy. Interviews with family members and staff revealed that notifications for care plan meetings were not effectively communicated, leading to family members missing these important meetings. Additionally, hospice staff were often not present at care plan meetings, and there was a lack of documentation regarding their absence. These deficiencies could result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status or healthcare decisions.
Failure to Administer Timely Antibiotics and Apply Compression Stockings
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two residents. For one resident, antibiotics were not started until five days after a positive urine culture for Escherichia Coli was received. The urine culture results were sent to the facility provider on the same day they were received, but the facility did not attempt to contact the provider until four days later. The antibiotics were subsequently ordered and started five days after the culture results were received. This delay was confirmed during an interview with the MDS coordinator and the DON. For another resident, the facility failed to apply compression stockings as ordered by the physician. The resident, who had a diagnosis of localized edema, was observed without compression stockings on multiple occasions. The physician's order to apply knee-high compression stockings in the morning and remove them at night was not included in the resident's care plan. Interviews with a CNA and an LPN revealed that they were unaware of the order for compression stockings, and the resident was not wearing them at the time of the interviews. The DON confirmed that CNAs are expected to apply and remove compression stockings as per the physician's order.
Failure to Lock Treatment Carts and Ensure Fall Mat Placement
Penalty
Summary
The facility failed to keep treatment carts locked when not supervised by staff, affecting all 53 residents in the East Unit and H Unit. Multiple observations over several days revealed that treatment carts were left unlocked and unattended. Staff members, including RNs, CMAs, and LPNs, confirmed during interviews that the treatment carts should be locked when not in use. The Director of Nursing (DON) also confirmed that treatment carts should be locked when staff are not present. Additionally, the facility failed to ensure that a fall mat was placed next to a high fall-risk resident's bed as specified in the care plan. The resident, who had a history of falls and was unable to get out of bed independently, was observed without a fall mat next to her bed. The fall mat was found folded up behind a recliner in the resident's room. Staff members, including a CNA and an LPN, confirmed that the fall mat should be placed next to the resident's bed to prevent injury. The DON also confirmed that the fall mat should be in place as per the care plan.
Failure to Document Rationale for Not Following Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the physician provided a rationale for not following the pharmacist's recommendations for two residents reviewed for unnecessary medications. For Resident #36, the pharmacist recommended increasing the dosage of Metformin from 500 mg twice daily to 500 mg three times daily. The provider denied this recommendation but did not provide a rationale for the decision. This was confirmed by the Director of Nursing (DON) during an interview. The physician's orders for Resident #36 continued to reflect the original dosage without any documented rationale for the denial of the pharmacist's recommendation. For Resident #41, the pharmacist recommended considering a reduction of either divalproex or Seroquel. The provider marked the gradual dose reduction (GDR) as contraindicated but did not document a rationale for this decision. The physician's orders for Resident #41 continued to include divalproex 125 mg twice a day and Seroquel 25 mg at bedtime without any changes or documented rationale for not following the pharmacist's recommendation. This lack of documentation was also confirmed by the DON during an interview.
Failure to Implement Gradual Dose Reduction and Document Rationale
Penalty
Summary
The facility failed to initiate a gradual dose reduction (GDR) of medication as recommended by the pharmacist and ordered by the facility provider for two residents. For one resident, the pharmacist recommended a GDR of Depakote and gabapentin due to frequent falls, daytime drowsiness, and irritability. The facility provider marked the GDR for Depakote as contraindicated and agreed to reduce gabapentin to 100 mg three times daily. However, the resident's medical record did not show a new order for the reduced gabapentin dose, and the resident continued to receive the same dose. The DON and MDS coordinator confirmed that the GDR had not been completed as agreed upon by the provider. For another resident, the pharmacist recommended a further reduction of divalproex or seroquel due to the resident not exhibiting behaviors. The provider marked the GDR as contraindicated but did not document a rationale for this decision. The resident's medical record did not contain information that the physician ordered a GDR for divalproex or seroquel after the pharmacist's recommendation. The DON confirmed that the provider did not document a rationale for not acting upon the pharmacist's recommendations and had not ordered a dose reduction for the medications.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications properly and ensure medication carts were locked for all 53 residents in the East Unit and the H Unit. During an observation, a medication cart on the H Unit was found unlocked without staff present. This was confirmed by an RN and the DON, who both acknowledged that medication carts should be locked when unattended. Additionally, loose medications were found in the medication carts on both units, including a half of a white round tablet and a white round tablet with the imprint HH 223. These observations indicate a failure to maintain proper medication storage protocols, which could lead to residents obtaining or being administered incorrect medications. Furthermore, the facility did not store insulin according to the manufacturer's instructions. An Admelog SoloStar insulin pen was found in the refrigerator with an open date of 03/01/24, despite the manufacturer's guidelines stating that the pen should be kept at room temperature and not refrigerated after opening. The DON confirmed that she was unaware of the proper storage requirements for Admelog. These deficiencies highlight significant lapses in medication management and storage practices within the facility.
Failure to Label Nasal Cannulas
Penalty
Summary
The facility failed to follow proper infection control practices for three residents who were observed using nasal cannulas without proper labeling. During observations, it was noted that the nasal cannulas for these residents were not labeled with the date they were changed, which is against the facility's practice of changing nasal cannulas weekly and dating them for tracking purposes. Specifically, Resident #14 was seen in the dining area with an unlabeled nasal cannula, and this was confirmed by RN #11. Resident #65 had an oxygen concentrator and a portable oxygen tank, both with nasal cannulas that were either illegibly labeled or not labeled at all, as confirmed by CNA #22 and RN #21. Resident #179, who had a physician's order to change the nasal cannula on the first Sunday of the month, was also observed with an unlabeled nasal cannula, confirmed by RN #11 and the DON. These observations indicate a failure in the facility's infection control practices, as staff did not adhere to the protocol of labeling nasal cannulas with the date they were changed. This deficiency was confirmed through multiple interviews with staff members, including RNs and CNAs, who acknowledged that nasal cannulas should be changed weekly and labeled accordingly. The lack of proper labeling could potentially lead to the spread of contagious and resistant illnesses among residents.
Deficient Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that call lights were functional and accessible in residents' bathrooms and bathing areas. Specifically, the pull cords for the call light system in the bathrooms were not within reach from the floor for ten residents. Additionally, the alarm sound for the call lights in two residents' rooms was not working, and the call lights were not within reach for two other residents. These deficiencies were confirmed through observations and interviews with residents and staff, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs). The Director of Nursing (DON) and the Administrator also confirmed that the call lights should be within reach and audible to alert staff when activated. For instance, one resident reported that her call light lit up but did not make an audible sound, and the pull cords in her bathroom were coiled up and not accessible. Another resident was found sitting in a chair with the call light placed on the bed behind him, making it impossible for him to reach it. Similarly, another resident lying in bed could not reach her call light, which was hung on the bed rail out of her reach. These observations were corroborated by staff interviews and care plan reviews, which indicated that the call lights should be kept within reach of the residents to ensure they can call for assistance when needed.
Failure to Provide Mandatory Training
Penalty
Summary
The facility failed to provide required training on abuse, neglect, and exploitation (ANE) and Dementia Management to several staff members. Specifically, CNA #26, LPN #21, LPN #22, and RN #21 did not complete the necessary training within the specified date range. The facility relies on face-to-face training sessions conducted monthly, covering different subjects each month. However, if a staff member misses a monthly session, they may miss mandatory training. This was confirmed during interviews with the Administrator and the Director of Nursing (DON). The lack of completed training could result in staff not knowing how to identify and report instances of abuse, neglect, and exploitation.
Inaccurate MDS Assessment for UTI Diagnosis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for one resident reviewed for MDS accuracy. Specifically, the resident complained of burning pain upon urination, and a McGreer's Criteria form indicated acute dysuria and a significant bacterial count in a urine sample. The resident was subsequently diagnosed with a urinary tract infection (UTI) and prescribed gentamicin. However, the quarterly MDS assessment did not document the UTI diagnosis. The MDS Coordinator confirmed the omission during an interview, acknowledging that the MDS assessment was not accurate for the resident.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for all 76 residents by not repairing broken roof tiles in the activity room. During an observation, it was noted that one ceiling tile had a corner piece broken off, a second tile had a corner piece broken off and was missing the corner of the tile, and a third tile had a crack on the corner. The Maintenance Director confirmed that roofing tiles were replaced but did not specify where and when. The Administrator confirmed that one tile in the activity room was cracked but did not see any other broken tiles, despite maintenance confirming replacements without specific details.
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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