Santa Fe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Fe, New Mexico.
- Location
- 635 Harkle Road, Santa Fe, New Mexico 87505
- CMS Provider Number
- 325030
- Inspections on file
- 24
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Santa Fe Care Center during CMS and state inspections, most recent first.
Two residents identified as high risk for falls did not have fall mats present as ordered by their physicians and care plans. Observations and interviews with staff and family confirmed that fall mats were missing while the residents were in bed, despite clear orders and care plan interventions requiring their use.
The facility did not ensure that a licensed pharmacist completed monthly drug regimen reviews for multiple residents and failed to implement pharmacy recommendations that were approved by providers. These lapses included not discontinuing pain medications, not monitoring for medication side effects, and not updating the EMR with new orders as required.
A resident was permitted by provider order to have one beer daily, with the beer to be stored in a locked refrigerator per the care plan. However, the resident kept beer in a cooler in his room and accessed it daily, with staff and family assisting, which did not align with the documented care plan. Both the DON and Administrator confirmed this inconsistency between the care plan and actual practice.
A resident on blood thinners experienced a significant forearm injury that was not promptly communicated to the Providers or DON. The injury was discovered in the morning by an RN and CNA, but the resident was not reassessed throughout the day, leading to increased bleeding and a delayed hospital visit. The NP and DON were not informed until the resident was sent to the ER, highlighting a failure in communication and documentation.
A resident on blood thinners suffered a self-inflicted forearm laceration that was not properly monitored or communicated between shifts, leading to worsening of the wound and hospitalization. The initial dressing was not reassessed throughout the day, and staff interviews revealed a breakdown in communication and adherence to care protocols.
A resident with Alzheimer's and limited mobility did not receive adequate toenail care, as required by their care plan. Despite complaints from the resident's family, the facility staff only trimmed the resident's toenails twice in a month, leading to an ER visit where hospital staff had to address the issue. The DON confirmed that toenail care was not performed as expected.
The facility failed to maintain accurate medical records for three residents, leading to potential miscommunication and inadequate care. One resident's non-weight bearing status was not documented, affecting his referral to a Home Health provider. Another resident's records lacked documentation of a significant change in condition and hospital transfer. A third resident's behavioral issues were not accurately recorded, despite multiple incidents. These deficiencies highlight lapses in record-keeping and communication within the facility.
A facility failed to report and investigate an injury of unknown origin for a resident. The DON spoke with an RN about the incident but did not conduct a complete investigation, believing it unnecessary. A unit investigation was conducted involving multiple residents and an RN, but the specific resident was not included. The ADM also did not complete an investigation, relying on the DON's incomplete unit investigation. Both the DON and ADM acknowledged the oversight.
A facility failed to update a resident's care plan to include the use of an anticoagulant, apixaban, as ordered by the physician. The resident's care plan addressed risks for falls due to confusion and balance issues but omitted the anticoagulant information. The DON confirmed that the staff should have updated the care plan but did not.
The facility failed to properly sanitize glucometers between uses during FSBS tests, leading to potential cross-contamination. Staff used alcohol wipes instead of the required antiviral wipes, and glucometers were inappropriately stored in clothing pockets. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as staff were unaware of EBP requirements and lacked necessary signage and PPE. The facility also failed to update infection control policies annually and did not have adequate water safety management controls.
The facility did not have a qualified Infection Preventionist (IP) with the necessary specialized training in infection prevention and control. The Administrator identified a staff member as the IP, but no certificate of completion was provided. The staff member confirmed they had only completed state training on COVID-19 and was in the process of obtaining further certification. The previous IP left in March, and the current Director of Nursing, who had been in the role for three weeks, had not yet received the required training.
The facility failed to maintain clean or dust-free filters on oxygen concentrators for five residents, increasing the risk of infection. Observations revealed dirty filters filled with lint and debris, and in some cases, missing filters. Staff interviews indicated confusion about who was responsible for cleaning the filters, with the Central Supply staff admitting to possibly missing checks. The DON and Administrator were unaware of the issue until it was pointed out, highlighting a breakdown in procedures for maintaining respiratory care equipment.
A facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included improper application of Lidoderm patches, failure to administer levothyroxine and lisinopril as ordered, and incorrect dosage of Vitamin B-12. Staff did not document refusals or ensure medications were given per physician orders.
A facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN), leaving them uninformed about potential non-coverage by Medicare and the associated costs. The Social Services Director and Business Office Manager did not issue the SNFABN form, and the resident was not given written notice of their financial responsibilities despite having remaining benefit days.
A resident admitted to hospice services with a terminal diagnosis did not have a Significant Change MDS completed within the required 14-day period. Despite the requirement in the RAI Manual, the facility failed to complete this assessment, as confirmed by interviews with MDS coordinators and the DON. This oversight could potentially place the resident at risk for unmet care needs.
A facility failed to complete a quarterly MDS assessment for a resident with multiple health conditions, missing the deadline by 25 days. The oversight was confirmed by MDS1, who acknowledged the error despite having a tracking system in place. The resident's previous assessments were completed, but the third quarterly assessment was not conducted as required by federal regulations.
The facility failed to accurately code the MDS for two residents receiving hospice services and one resident receiving insulin. One resident was incorrectly coded as not having a terminal condition or receiving hospice, despite being on hospice since June 2023. Another resident's MDS was inaccurately coded as not receiving hospice services, although they had been on hospice since March 2024. Additionally, a resident was incorrectly coded for insulin injections instead of semaglutide (Ozempic) injections. The MDS coordinator admitted to errors due to oversight and reliance on physician orders.
The facility failed to create comprehensive care plans for three residents, including one with end-stage renal disease requiring dialysis, another with acute respiratory failure needing supplemental oxygen, and a third with PTSD. Despite assessments indicating the need for specific care plans, these were not developed, as confirmed by staff interviews.
A resident was prescribed a 5% Lidoderm patch for shoulder pain, but an LPN administered a 4% patch due to insurance limitations. The MAR lacked dosage details, and the NP did not specify a dosage, assuming the 4% patch was standard. The DON confirmed that all medication orders should include dosage, revealing a policy-practice gap.
A resident experienced a gradual, unintentional weight loss over several months without adequate assessment or intervention by the facility. Despite being at risk for weight loss and dehydration, no significant dietary recommendations or weight loss plan were documented. The RD did not intervene, citing a lack of significant weight loss, and the DM failed to document communication with the RD. The facility's policy required monitoring and intervention, which was not followed, leading to a deficiency in care.
A resident with essential hypertension received lisinopril without consistent blood pressure monitoring, contrary to physician orders. The facility's records showed that blood pressure was not documented on many days, yet lisinopril was administered daily, even when the systolic blood pressure was below the prescribed threshold. The DON confirmed the expectation for blood pressure monitoring and acknowledged the oversight.
A resident admitted for rehabilitation services did not receive the ordered physical and occupational therapy evaluations due to a misunderstanding about her status as a long-term care resident. Despite the resident's care plan indicating a need for therapy to address fall risks, no evaluations were documented. The Director of Therapy confirmed the oversight, and the Administrator expected evaluations to be completed as ordered.
A facility failed to update the care plan for a resident with multiple diagnoses, including vascular dementia and ataxia, who sustained bruises on both hands. The bruises were caused by the resident's improper use of a wheelchair, which was not addressed in the care plan. Despite the resident's need for total assistance with wheelchair use, the care plan lacked this information, indicating a failure to provide appropriate care.
Failure to Provide Fall Mats as Ordered for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall mats were present for two residents identified as high risk for falls, as ordered by their physicians and outlined in their care plans. One resident, who had a history of confusion, gait and balance problems, and paralysis, was care planned to have a fall mat present when in bed. Multiple observations revealed that the fall mat was not present while the resident was in bed, and this was confirmed by the resident's daughter, a CNA, the Director of Rehab, and the DON, all of whom acknowledged that a fall mat should have been in place. Similarly, another resident with a physician order for a fall mat to be present when in bed was observed lying in bed without the required fall mat. This absence was confirmed by the Scheduler and the DON, both of whom stated that a fall mat should have been present according to the physician's order. These findings were based on direct observations, interviews with staff and family, and review of care plans and physician orders.
Failure to Complete Monthly Pharmacy Reviews and Implement Approved Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed the required monthly drug regimen reviews for several residents over multiple months. Specifically, pharmacy reviews were not completed for three residents from August 2024 through October 2025. Additionally, pharmacy recommendations that were approved by providers were not implemented for two residents. These recommendations included discontinuing certain pain medications and monitoring for dermatological side effects related to specific prescriptions. In another instance, recommendations to monitor for involuntary movements were approved but not carried out as ordered. Record reviews confirmed that the Medication Regimen Review (MRR) documentation was either missing or not acted upon, and interviews with the DON verified that these omissions occurred and should have been addressed. The failures included not adding new orders to the electronic medical record (EMR) after provider approval and not following through with monitoring or discontinuation of medications as recommended by the pharmacist and approved by the provider.
Failure to Implement Accurate Care Plan for Resident's Alcohol Storage
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered comprehensive care plan for a resident regarding the storage and access to beer, as ordered by the provider. Observation and interviews revealed that the resident kept a cooler with beer in his room and accessed it daily, consistent with his statement and the provider's order allowing one beer per day. However, the care plan documented that the beer should be stored in a locked refrigerator in the restorative area, not in the resident's room. Both the DON and Administrator confirmed the discrepancy between the care plan and the actual practice, with staff and family facilitating the resident's access to beer from the cooler in his room, contrary to the care plan instructions.
Failure to Notify Providers and DON of Resident's Injury
Penalty
Summary
The facility failed to notify the Providers and the Director of Nursing (DON) of a change in condition for a resident who experienced a large left forearm injury. The resident, who was on a blood thinner medication, was found with a significant skin tear by a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) in the early morning. The RN dressed the wound and reported the injury to the oncoming RN but did not notify the DON or the Provider. Throughout the day, the resident's condition was not reassessed, and no further documentation was made until the evening when the resident was sent to the emergency room due to increased bleeding. Interviews with the Nurse Practitioner (NP) and the DON revealed that they were not informed of the injury until the resident was sent to the hospital. The NP stated that she should have been notified immediately to provide additional treatment and potentially prevent the worsening of the injury. The DON confirmed that it was her expectation for the nursing staff to notify her and the facility providers immediately when a resident experiences a significant injury. The lack of communication and documentation likely contributed to the delay in appropriate medical intervention for the resident.
Failure to Monitor and Communicate Resident's Wound Care
Penalty
Summary
The facility failed to provide proper wound care and monitoring for a resident's left forearm laceration, which was discovered by a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) during the morning shift. The resident, who was on a blood thinner medication, was found with a large gash on the left forearm that appeared to be self-inflicted. The RN dressed the wound but did not clean it, and the severity of the injury was not effectively communicated to the oncoming day shift nurse or other relevant staff members. Throughout the day, the resident's wound was not reassessed, and no further documentation was made regarding the condition of the injury. The lack of monitoring and communication resulted in the wound bleeding profusely, necessitating the resident's transfer to the emergency room later that evening. Interviews with staff revealed a breakdown in communication, with the day shift nurse claiming she was not informed of the injury, and the wound care nurse not being made aware of the situation until after the resident returned from the hospital. The Director of Nursing (DON) and other staff members confirmed that the facility's protocol requires nurses to assess each resident every shift, which was not adhered to in this case. The failure to reassess and properly manage the resident's wound throughout the day led to the worsening of the injury, highlighting significant lapses in communication and adherence to care protocols within the facility.
Failure to Provide Adequate Toenail Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident, specifically in the area of toenail care. The resident, who had Alzheimer's disease, fatigue, impaired balance, and limited mobility, required staff assistance for ADL care. Despite the care plan indicating the need for such assistance, the facility's records showed that the resident's toenails were only trimmed and cleaned twice over a month-long period. This lack of regular care led to the resident being admitted to the emergency room, where hospital staff had to trim the resident's long toenails to improve mobility. Interviews with the resident's Power of Attorney and facility staff revealed that complaints about the resident's toenail care were made multiple times. A Certified Nursing Assistant (CNA) acknowledged receiving complaints from the resident's family and the facility's social worker. The CNA admitted that the resident's toenails appeared neglected despite the complaints. The Director of Nursing confirmed that the facility's expectation was for CNAs to check and care for residents' toenails during each shower, which was not done in this case.
Incomplete and Inaccurate Medical Records for Three Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential miscommunication and inadequate care. For the first resident, the medical records did not reflect his non-weight bearing status, which was crucial information for his referral to a Home Health provider. The resident was discharged from the facility without this critical information being documented, resulting in his inappropriate acceptance into a program that required weight-bearing capability. The Social Services Coordinator confirmed that the referral documentation lacked this essential detail. The second resident's medical records were incomplete, missing documentation of a significant change in her condition. The resident experienced difficulty breathing, was transferred to a hospital, tested positive for COVID-19, and later returned to the facility. However, her medical records did not include any notes about her breathing difficulties, hospital transfer, or return, which the Director of Nursing acknowledged should have been documented. For the third resident, the facility's records failed to accurately reflect his behavioral issues and incidents. Despite multiple reports of the resident refusing care, threatening staff, and exhibiting aggressive behavior, the daily care notes consistently described him as having a pleasant mood with no behaviors witnessed. The Administrator confirmed that these incidents were not documented in the resident's medical records, indicating a significant lapse in accurate record-keeping.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an investigation regarding an injury of unknown origin for a resident. The Director of Nursing (DON) spoke with a Registered Nurse (RN) about the incident but did not conduct a complete investigation, believing it unnecessary after the conversation. The DON conducted a unit investigation involving multiple residents and RN #1, who was involved in the incident, but did not specifically include the resident in question. The Administrator (ADM) also did not complete an investigation for the resident's injury, relying on the DON's unit investigation, which did not specifically address the resident's case. Both the DON and ADM acknowledged that the resident should have been included in the investigation but was not.
Failure to Update Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to update the care plan for a resident to include the use of an anticoagulant medication, apixaban, which was ordered by the physician. The resident was admitted and later discharged from the facility, and during their stay, a physician's order dated 07/09/24 indicated the need for apixaban, 5 mg twice a day. However, the care plan, which was supposed to address the resident's risk for falls due to confusion, balance, vision, and hearing problems, did not include any information about the anticoagulant use. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the staff should have updated the care plan to reflect the anticoagulant use but failed to do so.
Infection Control Deficiencies in Glucometer Sanitization and EBP Implementation
Penalty
Summary
The facility failed to properly sanitize glucometers between uses during fingerstick blood sugar tests (FSBS) for three residents, leading to potential cross-contamination. Observations revealed that a registered nurse (RN) and a licensed practical nurse (LPN) did not use the appropriate disinfecting wipes as per the facility's policy and instead used alcohol wipes, which are not sufficient for disinfection. The RN and LPN admitted to not following the correct procedure, and the Director of Nursing (DON) confirmed that the facility's policy required the use of antiviral wipes. The DON also noted that carrying the glucometer in a clothing pocket was inappropriate and posed an infection control issue. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters, suprapubic catheters, and feeding tubes. Observations and interviews with staff and residents indicated a lack of signage and personal protective equipment (PPE) in place for these residents. Staff members, including LPNs and certified nurse aides (CNAs), were unaware of the EBP requirements, and the facility's administrator did not recall receiving the relevant memo from the Centers for Medicare and Medicaid Services (CMS) regarding EBP implementation. Additionally, the facility did not update its infection control policies and procedures on an annual basis and lacked control measures to monitor their water safety management program. The maintenance director admitted to not having test results for Legionella and was under the impression that testing was conducted by the city. The administrator confirmed that the facility had not experienced any outbreaks but acknowledged that testing was not being conducted as part of their preventative maintenance program.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) with specialized training in infection prevention and control, as required by their policy. The policy, revised in September 2022, mandates that the IP must have evidence of training through a certificate of completion or equivalent documentation. During an entrance conference interview, the Administrator identified the Minimum Data Set (MDS) 1 as the IP since February 2024. However, upon review, no certificate was presented for the IP. In an interview, MDS1 confirmed being the IP as of the previous day and mentioned having taken state training on COVID-19 but had not completed other necessary training. The Administrator further explained that the former Director of Nursing (DON), who was the IP, left in March 2024, and the current DON, who had been in the position for three weeks, was yet to receive the required training. MDS1 was in the process of obtaining certification.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure that oxygen concentrators had clean or dust-free filters for five residents, which could increase the risk of infection and unnecessary respiratory treatment. The facility's policy required that oxygen concentrator filters be washed every seven days, but observations revealed that the filters were dirty and filled with lint and debris. For Resident 7, the oxygen concentrator filter was observed to have a significant buildup of white lint and debris over several days, and staff interviews indicated a lack of clarity about who was responsible for cleaning the filters. Resident 19's oxygen concentrator was also observed to have a dust-filled filter on multiple occasions. Similarly, Resident 16's oxygen concentrator had a dust-filled filter, and the Assistant Director of Nursing acknowledged the need for cleaning. Resident 47's oxygen concentrator was missing a filter entirely, and staff interviews revealed that nurses were expected to check the filters when changing tubing. Resident 132's concentrator also lacked a filter, and the Director of Nursing stated that the equipment should include inlet filters to prevent dust and other particles from entering. Interviews with staff, including Licensed Practical Nurses, Central Supply staff, and the Director of Nursing, highlighted a lack of communication and responsibility regarding the maintenance of oxygen concentrator filters. The Central Supply staff claimed to perform routine checks but admitted to possibly missing the filter on Resident 7's concentrator. The Director of Nursing and Administrator were unaware of the issue until it was brought to their attention, indicating a breakdown in the facility's procedures for ensuring proper respiratory care equipment maintenance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20% error rate during the survey. This was observed in the cases of three residents. For one resident, Lidoderm patches were not applied or removed as per the physician's orders. The resident was supposed to have patches applied to both shoulders in the morning and removed at bedtime, but this was not consistently done. The nurse involved stated that the resident sometimes refused the patches, but there was no documentation of such refusals or the removal of the patches at night. Another resident did not receive their prescribed medications, levothyroxine and lisinopril, as ordered. The LPN preparing the medications did not attempt to administer levothyroxine, assuming the resident would refuse it, and failed to administer lisinopril despite the resident's blood pressure being within the required range. The LPN admitted to not asking the resident if they wanted to take the levothyroxine and realized the error only after administering the other medications. A third resident received an incorrect dosage of Vitamin B-12. The resident was prescribed 500 mcg, but the LPN administered 1000 mcg because the facility only had 1000 mcg tablets available and staff were not allowed to split tablets. The LPN acknowledged the error and suggested ordering the correct dosage from the pharmacy. The facility's administration and DON stated that their expectation was for medications to be administered as ordered and for staff to inform residents of medication risks and benefits.
Failure to Provide SNFABN Documentation
Penalty
Summary
The facility failed to provide written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) for a resident reviewed for beneficiary notices. The resident, identified as R27, was not informed in writing about the potential non-coverage of services by Medicare, the reasons for this, or the estimated daily costs they would incur if they chose to continue receiving skilled services. This lack of documentation meant that the resident was unable to make an informed decision regarding their care and financial responsibilities. The facility's policy required that residents be informed verbally and in writing about Medicare and Medicaid benefits, including any changes to covered services. However, interviews with the Social Services Director (SSD) and the Business Office Manager (BOM) revealed that the SNFABN form was not issued to R27, and the BOM was unfamiliar with the form. Despite the resident having remaining benefit days, the facility did not provide the necessary documentation to R27, who chose to remain in the facility. The SSD acknowledged discussing costs verbally but did not provide the required written notice.
Failure to Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) within 14 days for a resident who was admitted to hospice services. The resident, who had a terminal diagnosis of sequelae of cerebrovascular disease, was admitted to hospice services on March 18, 2024. Despite the requirement outlined in the MDS-3.0 Resident Assessment Instrument (RAI) Manual, which mandates the completion of a Significant Change in Status Assessment (SCSA) whenever a resident elects the hospice benefit, the facility did not complete this assessment within the required timeframe. Interviews with facility staff, including the MDS coordinators and the Director of Nursing (DON), confirmed that the significant change MDS was not completed as required. The MDS coordinators acknowledged the oversight, stating that the assessment should have been completed within the 14-day period following the resident's admission to hospice services. The DON and the Administrator also expressed that their expectation was for the MDS to be completed accurately and timely, in accordance with the RAI manual. The failure to complete the significant change MDS could potentially place the resident at risk for unmet care needs.
Missed Quarterly MDS Assessment for a Resident
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for a resident, identified as R43, who was reviewed for completion of MDS assessments. The facility was overdue by 25 days in completing this assessment. According to the facility's policy, quarterly assessments are federally mandated under the Omnibus Budget Reconciliation Act (OBRA) and are required to be performed for all residents in Medicare and/or Medicaid certified nursing homes. These assessments are crucial for tracking the resident's status between comprehensive assessments and ensuring the monitoring of critical indicators of significant changes in resident status. R43 was admitted to the facility with multiple diagnoses, including type two diabetes mellitus, hypothyroidism, peripheral vascular disease, acute hematogenous osteomyelitis, end-stage renal disease, and a complete traumatic amputation of the right midfoot. The resident's admission MDS assessment was completed, followed by quarterly assessments on two occasions. However, the third quarterly MDS assessment, due by mid-June, was not completed. During an interview, MDS1 confirmed the oversight, stating that the assessment was missed despite having a calendar to track due dates and a system in place to ensure care plans were updated. MDS1 acknowledged the error, indicating that the resident's quarterly MDS assessment had been inadvertently skipped.
Inaccurate MDS Coding for Hospice and Insulin Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents receiving hospice services and one resident receiving insulin, which could potentially place the residents at risk for care needs not being addressed. For Resident 7, the MDS was incorrectly coded as not having a terminal condition or receiving hospice services, despite documentation indicating that the resident had been on hospice since June 2023 with a terminal diagnosis of malignant neoplasm of the brain. The MDS coordinator, MDS1, admitted to only reviewing physician orders and missing the correct coding due to system updates and oversight. Similarly, Resident 10's MDS was inaccurately coded as not having a terminal condition or receiving hospice services, even though the resident had been on hospice since March 2024 with a terminal diagnosis related to cerebrovascular disease. MDS1 acknowledged the error, citing the same reasons as with Resident 7, including a lack of thorough documentation review and reliance on physician orders alone. For Resident 29, the MDS was incorrectly coded to reflect insulin injections, although the resident was receiving semaglutide (Ozempic) injections for type two diabetes mellitus. MDS1 admitted to not knowing how to capture the injection for MDS assessment and payment purposes, leading to the inaccurate coding. The Director of Nursing and the Administrator expressed their expectation for MDS assessments to be coded accurately, but were unaware of the inaccuracies prior to the survey findings.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which is a deficiency in meeting the residents' needs. Resident 43, who was admitted with end-stage renal disease and a traumatic amputation, did not have a care plan for dialysis or the central venous catheter (CVC) despite having orders for dialysis and a CVC in place. The resident's quarterly Minimum Data Set (MDS) assessment indicated intact cognition and triggered the need for dialysis care planning, yet this was not reflected in the care plan. Interviews with MDS coordinators confirmed the absence of the necessary care plans. Similarly, Resident 47, admitted with acute respiratory failure requiring supplemental oxygen, did not have a care plan addressing oxygen needs, even though the MDS assessment triggered the need for such a plan. Observations confirmed the resident was using oxygen, but the care plan did not reflect this requirement. Additionally, Resident 67, diagnosed with post-traumatic stress disorder (PTSD), lacked a care plan for managing PTSD, despite the MDS assessment indicating the need for it. Interviews with staff confirmed the absence of these care plans, acknowledging that they should have been in place to address the residents' health and psychosocial issues.
Failure to Specify Dosage in Medication Order
Penalty
Summary
The facility failed to ensure a medication order was written to include the proper dosage for a prescribed medication, as observed in the case of a resident admitted with a diagnosis of pain in the right shoulder. The resident was ordered to receive a 5% Lidoderm patch for pain management, but during medication administration, an LPN applied a 4% Lidoderm patch instead. The LPN confirmed the use of the 4% patch, stating it was the only available option covered by insurance. Upon review, it was found that the medication administration record (MAR) did not specify the dosage for the Lidoderm patches. Further investigation revealed that the Nurse Practitioner (NP) intended for the resident to receive 4% patches due to insurance constraints, and she did not include a dosage in the order because the 4% patches were over-the-counter. The NP was unaware of how the 5% dosage appeared in the order. The Director of Nursing (DON) stated that the current standard of practice required all medication orders to include a dosage, highlighting a discrepancy between the facility's policy and the actual practice observed.
Failure to Address Gradual Weight Loss in Resident
Penalty
Summary
The facility failed to adequately assess and address the cause of a continual, gradual, and unintentional weight loss for a resident, identified as R12, who was reviewed for nutrition among a sample of 20 residents. R12 was admitted with multiple diagnoses, including multiple sclerosis and hypertension, and was on a regular diet with pureed texture and thin liquids. Despite a documented gradual weight loss over several months, no significant interventions or assessments were implemented to prevent further weight loss. The facility's policy required monitoring and documentation of weight and dietary intake, with interventions based on identified causes. However, R12's records showed a weight loss of 7.5% over six months, with no documented evidence of an assessment or evaluation by the Registered Dietician (RD) after a referral was made in May 2024. The care plan noted R12 was at risk for weight loss and dehydration, but no dietary recommendations or weight loss plan were documented. Interviews with the RD and Dietary Manager (DM) revealed a lack of communication and documentation regarding R12's weight loss. The RD stated she only intervened in cases of significant weight loss and did not recall being informed of R12's situation. The DM acknowledged providing dietary interview information to the RD but did not document it. The Administrator and Director of Nursing (DON) confirmed that the RD should have identified and implemented interventions for R12's gradual weight loss.
Failure to Monitor Blood Pressure Before Administering Lisinopril
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not adhering to physician-ordered blood pressure monitoring prior to administering lisinopril, a medication used to treat hypertension. The resident, identified as R48, was readmitted with a diagnosis of essential hypertension and had specific physician orders to withhold lisinopril if the systolic blood pressure was less than 100. However, the facility's records showed that blood pressure was inconsistently monitored, with significant gaps in documentation over several months. Despite these gaps, lisinopril was administered daily, even on days when the recorded systolic blood pressure was below the threshold of 100. The facility's policy required the evaluation of medication effectiveness and potential problems, but this was not followed in R48's case. Observations and interviews revealed that the blood pressure monitoring equipment was set to automatically record readings in the electronic medical record, yet this process was not consistently followed. The Director of Nursing confirmed that the expectation was for blood pressure to be recorded if there were specific parameters to follow, and acknowledged that the administration of lisinopril should have been withheld when the systolic blood pressure was below 100. This oversight had the potential to cause adverse consequences for the resident.
Failure to Conduct Ordered Therapy Evaluations
Penalty
Summary
The facility failed to conduct physical and occupational therapy evaluations as ordered by the physician for a resident, identified as R231, who was reviewed for rehabilitation services. R231 was admitted to the facility with diagnoses including type two diabetes mellitus, major depressive disorder, muscle weakness, reduced mobility, and a need for assistance with personal care and continuous supervision. The resident's care plan highlighted a risk for falls due to confusion, deconditioning, and unawareness of safety needs, with interventions including physical therapy evaluation and treatment as ordered or needed. However, there was no documented evidence in the electronic medical record that R231 had been evaluated for these therapies. Interviews conducted during the investigation revealed that R231 had not received the expected rehabilitation services. The resident expressed that she was supposed to be on rehabilitation services, which was the reason for her admission to the facility. The Director of Therapy confirmed that evaluations had not been conducted, citing a misunderstanding that R231 was a long-term care resident and private pay, which led to the omission. The Director of Therapy acknowledged that a quick screening was done, but emphasized that the best practice would have been to perform the evaluations. The facility's Administrator stated that it was his expectation for therapy evaluations to be completed as ordered by the physician.
Failure to Update Care Plan for Resident with Unwitnessed Injuries
Penalty
Summary
The facility failed to revise and update the care plan for a resident who experienced unwitnessed injuries. The resident, who was admitted with multiple diagnoses including vascular dementia with behaviors, major depression, late-onset cerebellar ataxia, and cognitive communication deficits, had bruises on both hands. These bruises were first noted in daily care notes and a nurse's skin check, and were later brought to the attention of the staff by the resident's daughter. An investigation revealed that the bruises were caused by the resident grabbing the wheels of his wheelchair in a manner that led to bruising. Despite the findings, the resident's care plan did not include instructions for staff to provide total assistance with wheelchair use, which was necessary to prevent further injury. The registered nurse confirmed that the care plan lacked this critical information, indicating a failure to update the care plan to reflect the resident's current care needs and treatments. This oversight suggests that the facility may not have been providing the appropriate care to meet the resident's needs.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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