St. Anthony Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clovis, New Mexico.
- Location
- 1400 West 21st Street, Clovis, New Mexico 88101
- CMS Provider Number
- 325076
- Inspections on file
- 23
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at St. Anthony Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents were administered medications such as Ativan, Trazadone, Hydroxyzine, and Lorazepam for agitation, anxiety, and insomnia without corresponding diagnoses documented in their EHRs. The DON confirmed these medications were given for the indicated uses, but the lack of documented indications led to a deficiency in ensuring drug regimens were free from unnecessary drugs.
Several residents reported filing grievances about food and showers but did not receive any outcomes or responses. The facility's policy requires documentation and response to grievances, but the Administrator could not provide evidence of investigations or communication of outcomes due to missing records.
Surveyors found that a medication cart and a treatment cart were left unlocked and unattended in the facility. Interviews with two LPNs confirmed the carts were not secured, and the DON stated that all medication carts should be locked when unattended. This failure affected all residents in the facility.
The facility did not provide meals that were palatable, attractive, or served at safe and appetizing temperatures. Two residents reported that food was often cold and did not match the posted menu, with one resident documenting multiple discrepancies between meal tickets and actual food served. Direct observation confirmed that hot foods were served below appropriate temperatures, and staff acknowledged these temperatures were not suitable for serving.
Surveyors observed peeling and chipped paint, unrepaired wall sections, and worn handrails in one hall, along with frequent use of an overhead paging system to call staff and maintenance. The Administrator confirmed these issues, which resulted in a failure to provide a comfortable, homelike environment for residents.
The facility did not have evidence of investigations into allegations of abuse, neglect, exploitation, or mistreatment for a period of several months after the previous Social Services Director left and took the Reportable Binder containing all related documentation. This resulted in a lack of records to show that such allegations were thoroughly investigated for all residents during that time.
Two residents had discrepancies between their care plans and their most current medical orders, including conflicting code statuses and outdated care preferences. The DON confirmed that care plans were not revised after changes in hospital status or resident preferences, resulting in inaccurate documentation of resuscitation status and bathing routines.
A resident who was dependent on staff for ADL support did not receive proper bathing or showering assistance, as records showed only intermittent bed baths were provided over several months. The DON confirmed that bathing services were not adequately delivered.
Staff did not implement or document required fall prevention and post-fall interventions for two residents with severe cognitive impairment and a history of falls. Despite known risks and requests from a guardian, interventions such as keeping the bed in a low position and using a fall mat were not in place, and neurochecks were not performed after falls. Documentation regarding the cause and circumstances of falls was also incomplete, as confirmed by the DON.
Three residents with significant respiratory and chronic health conditions were found using oxygen concentrators without proper labeling to indicate when the tubing was last changed, and in one case, a concentrator was assigned to the wrong individual. Medical orders required weekly tubing changes and labeling, but staff did not consistently follow these protocols, as confirmed by the DON.
A resident's advance directive and MOST form indicated Full Code status, while the physician's orders in the EHR listed Do Not Resuscitate (DNR). The DON confirmed the resident should be Full Code, revealing the resident's medical chart was not updated to reflect the correct code status.
A resident admitted after hip surgery did not receive prescribed pain medications, leading to severe pain and a call to 911. Despite having orders for Gabapentin, Norco, and Ibuprofen, the facility did not administer any medications, offering only Tylenol, which was not ordered. The resident discharged against medical advice due to inadequate pain management.
The facility failed to provide meals that were attractive, palatable, and at a safe temperature, as reported by several residents. Observations showed overcooked and dry chicken, overly soft vegetables, and grievances about soggy sandwiches and undercooked desserts. A staff member confirmed ongoing complaints about food quality.
A resident admitted with multiple diagnoses, including a Stage 3 pressure ulcer, did not have their care plan updated with necessary wound care interventions until 25 days after admission. The DON confirmed that the care plan was not comprehensive, as it lacked interventions for pressure ulcers, which should have been included within seven days of the comprehensive assessment.
A resident was discharged without a comprehensive summary, leading to confusion at the receiving facility. The discharge plan lacked updated medication orders and care recommendations, and the MAR was outdated. The receiving facility struggled to clarify the resident's care needs due to unreturned calls from the discharging facility.
The facility failed to maintain safe water temperatures in the dementia care unit, with temperatures reaching up to 125°F, posing a risk of burns to residents with cognitive impairments. Additionally, the facility did not provide adequate supervision to prevent falls for a resident with severe cognitive impairment, resulting in multiple falls and injuries without proper assessment or intervention. These deficiencies highlight significant lapses in ensuring a safe environment for residents.
The facility failed to maintain proper food storage temperatures, with the walk-in refrigerator at 49°F, above the recommended range. Perishable items were improperly stored, and the Dietary Manager acknowledged the issue. Additionally, improper hand hygiene practices were observed, with Cook1 using a sanitizer not intended for hand use. Unsanitary conditions and expired food items were found in the kitchen and dementia care unit, violating facility policies.
The facility failed to maintain the walk-in refrigerator at a safe temperature, risking food-borne illness for all 59 residents. The refrigerator was observed at 49°F, above the safe limit, with various perishable foods stored inside. Despite a high-priority work order submitted months ago, the issue remained unresolved due to vendor difficulties, as confirmed by the Maintenance Director.
The facility failed to provide restorative services as ordered for five residents, leading to potential decline in their functional abilities. Residents with various diagnoses, including quadriplegia, schizophrenia, and muscle weakness, did not receive the prescribed range of motion exercises and other restorative interventions consistently. Staffing issues, particularly with a CNA responsible for multiple duties, contributed to the lack of services. The facility's policy emphasized maintaining residents' functional abilities, but gaps in care were evident.
The facility failed to provide an ongoing program of activities for residents on the dementia care unit, affecting several severely cognitively impaired individuals. Observations showed residents wandering without engagement, and staff confirmed the absence of an Activity Aide. The deficiency was due to staffing issues, with no activities conducted since January 2024, except briefly in June.
The facility failed to maintain an environment free of flies, affecting all residents. Flies were observed in resident rooms, dining areas, and therapy rooms, landing on residents and their food. Residents, including those with dementia and physical limitations, expressed dissatisfaction with the persistent fly problem. The issue was partly due to a broken fly curtain at the smoking area door, which had been unrepaired for ten months. The facility had a pest control contract, but the use of pest spray inside was not possible.
The facility did not ensure two cognitively intact residents participated in their care planning. Despite policy requirements, there was no documentation of invitations or attendance for care plan meetings, as confirmed by the Social Service Director.
The facility failed to prevent cross-contamination during medication administration and wound care. An LPN did not perform hand hygiene between resident contacts while administering medications, contrary to facility policy. Additionally, another LPN did not change gloves or perform hand hygiene during wound care for a resident with pressure ulcers, increasing the risk of infection. These actions were confirmed by the staff involved.
The facility did not post the actual hours worked by nursing staff, affecting all residents and visitors. Observations revealed no staffing information was displayed, and interviews with the Administrator and DON confirmed the sheets were inaccessible due to issues with the posting area. Staffing sheets were kept in a box and a drawer, contrary to policy requirements.
Failure to Document Indications for Psychotropic and Sedative Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs by not providing adequate indications of use for certain medications based on the residents' diagnoses. For three residents reviewed, physician orders included medications such as Ativan, Trazadone, Hydroxyzine, and Lorazepam prescribed for conditions like agitation, anxiety, and insomnia. However, record reviews revealed that the corresponding diagnoses for agitation and insomnia were not documented in the residents' electronic health records (EHRs). For example, one resident was prescribed Ativan for agitated behavior and Trazadone for insomnia, but neither agitation nor insomnia was listed as a diagnosis in the EHR. Another resident was prescribed Lorazepam for agitation/anxiety, but anxiety was not documented as a diagnosis. Similarly, a third resident was prescribed Trazadone for insomnia without insomnia being listed as a diagnosis in the EHR. During an interview, the Director of Nursing confirmed that these medications were being administered for the indicated uses as per the physician's orders, despite the lack of corresponding diagnoses in the residents' records. The absence of documented indications for these medications constitutes a failure to ensure that drug regimens are free from unnecessary drugs, as required by regulation.
Failure to Investigate and Communicate Grievance Outcomes
Penalty
Summary
The facility failed to conduct in-depth investigations, correct grievance allegations, and notify residents of the outcomes of their grievances, as required by its own policy. Multiple residents reported filing several grievances regarding issues such as food and showers, but stated they never received any outcomes or responses. Review of the facility's Grievance/Concern policy confirmed that staff are required to document all grievances and provide responses to residents. During interviews, the Administrator was unable to provide evidence of grievances, investigations, corrective actions, or communication of outcomes, citing that the previous Social Services Director had taken the grievance binder and a new binder was only started recently.
Medication and Treatment Carts Found Unlocked
Penalty
Summary
Surveyors observed that both a medication cart and a treatment cart were left unlocked and unattended in the facility. On two separate occasions, the medication cart was found unlocked by a resident room and the treatment cart was found unlocked near the nurse's station. Interviews with two LPNs confirmed that the carts were not secured at the time of observation. The Director of Nursing also stated that all medication carts should be locked when unattended. These findings indicate that the facility failed to ensure that drugs and biologicals were stored in locked compartments as required for all 62 residents identified in the facility census. No specific residents were identified as being directly involved or affected at the time of the observations, and no additional medical history or resident conditions were noted in the report.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature, as evidenced by record review, interviews, and direct observation. One resident, who was cognitively intact and had multiple medical diagnoses including spinal stenosis, diabetes, depression, and chronic heart failure, reported that the food did not taste good, was often served cold when it should have been hot, and that the facility did not follow the posted menu. Photographic evidence provided by the resident showed multiple instances where the food served did not match the items listed on the meal tickets, with substitutions and omissions occurring repeatedly across several meals. Another resident also reported that hot food was served cold and described the food as inedible, leading him to purchase and store his own food in his room. During a lunch meal observation, the internal temperatures of chicken and pizza served to residents were measured at 109.3°F and 112.6°F, respectively, which were confirmed by both a CNA and a dietary aide to be below appropriate serving temperatures. These findings demonstrate a consistent failure to serve meals according to the planned menu and at safe, appetizing temperatures.
Failure to Maintain Homelike Environment and Minimize Overhead Paging
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in the 200-hall. Observations revealed peeling and chipped paint on the walls throughout the 200-hall, and a section of wall near the therapy entrance that was not repainted to match the surrounding area after an object was removed. Additionally, the handrails in the 200-hall appeared worn and in need of repair or refinishing. These physical deficiencies were directly observed during a facility walkthrough. The facility also used an overhead paging system to announce phone calls for staff and to call staff members and maintenance to the office. Multiple announcements were made over the paging system during the surveyor's observations. During an interview, the Administrator confirmed that the environment was not as comfortable and homelike as desired, acknowledging the issues identified.
Lack of Documentation for Abuse and Neglect Investigations
Penalty
Summary
The facility failed to maintain evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. During an interview, the Administrator stated that there was no documentation of any investigations conducted since the beginning of the year because the previous Social Services Director took the Reportable Binder, which contained all investigation records, upon leaving the facility. As a result, there was a gap in documentation and evidence of investigations for several months, affecting the ability to demonstrate that allegations were properly addressed for all 62 residents in the facility during that period.
Failure to Maintain Accurate and Updated Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were accurate and up to date, as required. For one resident, the care plan listed a do not resuscitate (DNR) code status, while the most current New Mexico Orders for Scope and Treatment (MOST) form indicated an attempt resuscitation code status. This discrepancy was not corrected after the resident returned from the hospital, as confirmed by the Director of Nursing (DON) during an interview. The resident's medical history included spinal stenosis, type 2 diabetes mellitus with hyperglycemia, depression, and chronic diastolic heart failure. The resident was also assessed as cognitively intact. For the second resident, the care plan did not reflect updated preferences for bathing frequency, as the Bathing Preference Sheet was changed to once a week, but the care plan still indicated a choice between bed baths or showers twice per week. Additionally, the care plan listed a DNR code status, while the MOST form indicated an attempt resuscitation code status. The DON confirmed that the care plan should have been revised to match the most current MOST form and to include a care plan for refusals of care, but these updates were not made.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and showering, for a dependent resident. Record review of the resident's documentation from 11/28/24 through 04/28/25 showed that the resident only received bed baths on several occasions, with no evidence of showers or full bathing being provided during this period. This lack of proper bathing assistance was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to provide these services.
Failure to Implement and Document Fall Prevention and Post-Fall Interventions
Penalty
Summary
Staff failed to implement and document necessary fall prevention and post-fall interventions for two residents with significant cognitive and physical impairments. One resident, with diagnoses including dementia, major depressive disorder with psychotic symptoms, reduced mobility, and delusional disorders, required substantial assistance with transfers and had a history of falls. Despite the resident's guardian requesting the bed be kept in a low position and a fall mat be used, neither intervention was in place. The resident's care plan did not include these interventions, and after an unwitnessed fall, there was no evidence that neurochecks were performed. The Director of Nursing confirmed these interventions were not implemented as required. Another resident, also with severe cognitive impairment and a history of falls, had multiple falls documented without adequate information regarding the cause or circumstances of the incidents. The care plan identified the resident as being at risk for falls and directed staff to monitor for changes that could increase fall risk. However, documentation was insufficient to determine the cause of the falls, and neurochecks were not completed following the incidents. The Director of Nursing acknowledged the lack of documentation and post-fall assessments.
Failure to Change and Label Oxygen Tubing per Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents who required oxygen therapy. For each resident, observations revealed that the oxygen concentrator tubing either lacked a label indicating when it was last changed or was not changed as ordered. In one instance, a resident was found using an oxygen concentrator with another resident's name on the attached bag, and there was no documentation of when the tubing was last replaced. The Director of Nursing (DON) confirmed these findings and stated that her expectation was for each resident to have a dedicated oxygen concentrator and for tubing to be changed and labeled as ordered. Medical records for the affected residents showed diagnoses including chronic obstructive pulmonary disease (COPD), quadriplegia, type 2 diabetes mellitus, morbid obesity, acute and chronic respiratory failure, essential hypertension, obstructive sleep apnea, and chronic congestive heart failure. Despite having medical orders specifying the frequency for changing oxygen concentrator tubing and labeling it with the date, staff did not consistently follow these orders, as evidenced by the lack of labeling and uncertainty regarding equipment assignment.
Failure to Update and Reconcile Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive and New Mexico Orders for Scope of Treatment (MOST) form were consistent with the physician's orders documented in the electronic health record (EHR). Record review showed that the resident's physician orders indicated a Do Not Resuscitate (DNR) status, while the current advance directive and MOST form reflected a Full Code status. During an interview, the Director of Nursing (DON) confirmed that the resident's code status should be Full Code, not DNR, highlighting the inaccuracy and lack of update in the resident's medical chart. This discrepancy was identified for one of two residents reviewed for advance directives.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who was admitted following hip surgery. Upon admission, the resident had physician's orders for Gabapentin, Norco, and Ibuprofen to manage her pain. However, the facility did not administer any of these medications during her stay. The resident complained of severe pain, rated at an eight on a scale of ten, and requested her prescribed medications. Instead, the nurse offered Tylenol, which was not part of the resident's medication orders, while waiting for the pharmacy delivery. The Medication Administration Record confirmed that no medications were administered to the resident during her stay. The resident's pain was not alleviated, leading her to call 911 for assistance and subsequently discharge herself against medical advice. Interviews with the Director of Nursing and the Assistant Director of Nursing revealed that pain medications should have been available through the facility's medication dispensing systems, such as the Nexus and E-Kit, without waiting for pharmacy delivery. The failure to provide the prescribed pain relief resulted in the resident experiencing significant pain and leaving the facility prematurely.
Deficient Meal Quality and Presentation
Penalty
Summary
The facility failed to ensure that meals served to residents were attractive, palatable, and at a safe and appetizing temperature. Multiple residents expressed dissatisfaction with the food, describing it as lacking flavor, being lukewarm, unrecognizable, and sometimes cold. Observations in the kitchen revealed that food items such as chicken tenders and mixed vegetables were not prepared to a satisfactory standard, with the chicken appearing overcooked and dry, and the vegetables being overly soft. Additionally, grievances from residents highlighted issues such as soggy sandwiches, overcooked pasta, and finding hair in food, indicating ongoing concerns with meal quality. Interviews with residents and a family member further emphasized the dissatisfaction with the facility's food, with complaints about the food's appearance, taste, and temperature. A staff member anonymously confirmed that there were ongoing complaints about the food quality. The grievances reviewed also included a complaint about a blueberry cobbler that was not fully cooked, causing a resident to feel sick. These findings suggest a pattern of inadequate meal preparation and presentation, impacting residents' dining experience and potentially their nutritional intake.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident, leading to a deficiency in care. The resident was admitted with multiple diagnoses, including a Stage 3 pressure ulcer, Type 2 diabetes mellitus, and long-term use of insulin and anticoagulants. Despite these conditions, the care plan was not updated to include necessary interventions for wound care until 25 days after admission. This delay in updating the care plan did not meet the expectations of the Director of Nursing, who stated that the comprehensive care plan should have been completed within seven days of the comprehensive assessment. The resident's care plan initially lacked interventions for the treatment of pressure ulcers, which were only added after a significant delay. The Director of Nursing confirmed that the care plan was not comprehensive, as it failed to include needed interventions for pressure ulcers, including a Stage 3 ulcer to the coccyx and a surgical incision to the back of the neck upon admission, as well as in-house acquired wounds such as a Stage 3 ulcer to the left heel and a deep tissue injury to the right heel. This oversight in care planning could potentially lead to a worsening of existing wounds or the development of new ones.
Incomplete Discharge Summary and Communication Failure
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, which included a recapitulation of the resident's course of treatment and a reconciliation of all medications at the time of discharge. The resident was admitted with multiple diagnoses, including a fracture of the humerus, type 2 diabetes, long-term use of insulin and anticoagulants, and pressure ulcers. Upon discharge, the Medication Administration Record (MAR) provided was outdated, listing medications that had been discontinued according to the resident's History and Physical assessment. Additionally, the discharge plan lacked any current medication orders, recommendations for care, or updates on the resident's ability to use his arm for activities. The receiving facility's staff encountered difficulties due to the lack of communication and incomplete discharge documentation. The Director of Nursing (DON) at the receiving facility reported that they were unsure of the resident's current medication regimen and had to schedule further tests for the resident's arm due to missing information about the fracture. Attempts to contact the discharging facility for clarification were unsuccessful, as the staff did not return calls. The DON at the discharging facility acknowledged the failure to communicate and confirmed that a comprehensive discharge plan was not created for the resident's transfer.
Deficiencies in Water Temperature Management and Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in the dementia care unit. Water temperatures were recorded to be excessively high, reaching up to 125 degrees Fahrenheit, which is above the safe limit of 120 degrees Fahrenheit. This issue affected six residents, all of whom had varying degrees of cognitive impairment, making them particularly vulnerable to the risk of burns. Despite initial adjustments to the water temperature, there was no consistent monitoring or documentation of water temperatures in resident rooms, leading to continued exposure to potential harm. Additionally, the facility failed to provide adequate supervision to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident experienced multiple falls, some resulting in injuries, without proper assessment or implementation of effective interventions to prevent future incidents. The resident's care plan included interventions such as a low bed and fall mats, but these measures were insufficient, as evidenced by the resident's repeated falls and injuries. The facility's documentation was lacking in assessments and investigations into the causes of the falls and injuries, and there was no evidence of additional interventions being put in place. The facility's inaction in both maintaining safe water temperatures and preventing falls placed residents at risk of serious injury. The lack of consistent monitoring and documentation, as well as the failure to implement effective interventions, highlights significant deficiencies in the facility's ability to provide a safe environment for its residents. These deficiencies were identified by surveyors, who noted the potential for serious harm due to the facility's failures.
Removal Plan
- Implementation of a removal plan through observations of water temperatures
- Review of education documentation
- Interviews with staff and the professional plumber
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage temperatures, as observed during a survey. The walk-in refrigerator was found to be at 49 degrees Fahrenheit, which is above the recommended temperature range of 35 to 40 degrees Fahrenheit. This refrigerator contained various perishable items, including roasts, lettuce, mayonnaise, and potatoes, which were not stored at the required temperature of 41 degrees Fahrenheit or below. The Dietary Manager acknowledged the issue, stating that the refrigerator had been malfunctioning for four months, and a work order had been submitted for repairs. Additionally, the lettuce was noted to be turning brown, and the facility's policy on cold food storage was not adhered to. The facility also failed to ensure proper hand hygiene practices in the kitchen. Cook1 was observed using a quaternary sanitizer to clean her hands between handling soiled and clean dishes, which is not an approved method for hand sanitization. The District Manager of the contracted dietary service confirmed that this was not the correct procedure, and the facility's handwashing policy required washing hands after contact with soiled equipment. The sanitizer used was intended for surface disinfection, not for hand sanitization, as per the manufacturer's instructions. Additional observations revealed unsanitary conditions in the kitchen, including soiled containers and sticky cabinet doors. Expired food items were found in both the main kitchen and the dementia care unit's refrigerator/freezer. These included cottage cheese, Knorr Vegetable Base, and various frozen dinners, all past their use-by dates. The facility's policy on safe food handling from visitors was not followed, as expired items were not discarded, and the storage area was not monitored daily as required.
Failure to Maintain Safe Refrigerator Temperature
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at a safe operating temperature, which had the potential to affect all 59 residents by risking food-borne illness. During an observation, the refrigerator's temperature was recorded at 49 degrees Fahrenheit, which is above the safe temperature range for storing perishable foods. The refrigerator contained various food items, including roasts, lettuce, mayonnaise, alfredo sauce, potatoes, margarine, and angel food cake. The Dietary Manager confirmed the temperature issue and acknowledged that the refrigerator had been problematic for the past four months. Despite submitting a high-priority work order to the Maintenance Director, the issue remained unresolved. The facility's policy requires perishable foods to be stored at 41 degrees Fahrenheit or below, except during preparation and service. However, the refrigerator's temperature exceeded this limit, with food items like potatoes and lettuce also recorded at unsafe temperatures. The Maintenance Director admitted to receiving the work order but cited difficulties in securing vendors to address the problem. This inaction led to the continued use of a malfunctioning refrigerator, posing a risk to the residents' health due to improper food storage.
Failure to Provide Ordered Restorative Services
Penalty
Summary
The facility failed to provide restorative services as ordered by the physician for five residents, leading to potential avoidable decline in their functional abilities. Resident 37, diagnosed with quadriplegia and contractures, was supposed to receive passive range of motion exercises five times a week. However, records showed that these exercises were only provided 11 out of 20 possible times, and the resident reported not receiving the services as expected. Similarly, Resident 54, with diagnoses including schizophrenia and dementia, was to receive active range of motion exercises seven times a week but only received services on 12 out of 25 days. The resident indicated that the staff responsible for her therapy was often unavailable due to other duties. Resident 46, with conditions such as spinal stenosis and diabetes, was ordered to have bilateral lower extremity exercises five times a week but only received them seven to eight times in July, with two refusals documented. Resident 11, who had kidney failure and muscle weakness, was supposed to resume restorative nursing with exercises three times a week but had no documented evidence of receiving any services. Lastly, Resident 34, with schizophrenia and muscle weakness, was to have hand carrots applied daily, but there was no physician's order for this, and the resident reported having to apply them herself when possible. Interviews with staff revealed that the lack of restorative services was due to staffing issues, particularly with CNA1, who was also responsible for driving the facility's van, leaving no time for restorative duties. The MDS Coordinator acknowledged awareness of the gaps in care and had raised concerns with management. The facility's policy on restorative nursing emphasized the importance of maintaining residents' functional abilities, but the lack of consistent restorative services as ordered was evident in the documentation and resident reports.
Lack of Activities for Dementia Care Unit Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and interests of residents on the dementia care unit, affecting five out of six residents reviewed. These residents, who were severely cognitively impaired, were observed without engagement in meaningful activities, despite their care plans indicating the importance of such activities. The care plans for these residents included interventions like encouraging participation in activities such as bingo, arts and crafts, and pet visits, but these were not implemented. Observations over several days revealed that residents were left to wander the halls or sit idly without any structured activities. Staff interviews confirmed the absence of an Activity Aide on the dementia care unit, which resulted in no activities being conducted. The lack of activities led to residents exhibiting behaviors such as repeatedly attempting to open locked doors and expressing confusion about meal times. The Activity Director and the Administrator acknowledged the lack of activities, citing staffing issues as the reason. The facility's policy emphasized the importance of a person-centered recreation program to maintain and improve residents' well-being, but this was not adhered to. The deficiency was attributed to the absence of dedicated staff to facilitate activities, which had not been consistently provided since January 2024, except for a brief period in June 2024.
Fly Infestation in Facility
Penalty
Summary
The facility failed to maintain an environment free of flies, which were observed in various areas including resident rooms, dining rooms, hallways, and the therapy room. This deficiency was noted during observations and interviews with residents and staff. Residents reported that flies were a persistent issue, particularly during mealtimes, and were seen landing on residents and their food. The presence of flies was a concern for residents, some of whom were unable to swat them away due to physical limitations. Several residents, including those with dementia, spinal stenosis, atrial fibrillation, quadriplegia, and traumatic brain injury, were affected by the fly infestation. These residents were cognitively intact and expressed their dissatisfaction with the fly problem. One resident mentioned that the flies had been an issue since their admission, while another resident noted that flies landed on a sore on their leg. The problem was exacerbated by a broken fly curtain at the smoking area door, which had been in disrepair for at least ten months. The Maintenance Director acknowledged the fly problem and attributed it partly to the broken fly curtain. The facility had a contract with a pest control company that sprayed outside every two weeks, but the use of pest spray inside the building was not possible. The Director of Nursing also acknowledged the issue, stating that flies were a constant problem despite efforts to keep doors closed and maintain cleanliness. The facility's policy on infection control and pest management was reviewed, indicating a commitment to providing a pest-free environment through contracted services.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure the participation of two residents in the development and implementation of their person-centered care plans. Resident 32, who was cognitively intact with a BIMS score of 15, was not involved in her care plan meeting, and there was no documentation to show she was invited or attended. Despite the facility's policy requiring resident involvement, the Social Service Director (SSD) could not provide evidence of an invitation or attendance for Resident 32. Similarly, Resident 48, also cognitively intact with a BIMS score of 15, reported not having attended a care plan meeting since admission. Although a letter was provided for a care plan conference, there was no documented evidence of Resident 48's invitation or attendance at any care plan meetings. The facility's policy emphasizes the resident's right to participate in their care planning, but the SSD was unable to provide documentation supporting the residents' involvement.
Inadequate Infection Control During Medication Administration and Wound Care
Penalty
Summary
The facility failed to administer medications in a manner that prevents cross-contamination for five residents during a medication pass. An LPN was observed not performing hand hygiene between resident contacts while administering medications, including blood pressure checks and handling inhalers. The LPN confirmed during an interview that she did not perform hand hygiene between residents, which contradicts the facility's policy requiring hand hygiene before and after resident care and contact with the resident's environment. The Director of Nursing also stated that hand sanitizer should be used after contact with each resident, and hands should be washed after every three resident contacts or when using liquids or injections. Additionally, the facility failed to complete wound care in a manner that prevents cross-contamination for a resident with pressure ulcers. An LPN was observed not changing gloves or performing hand hygiene between steps of the wound care process, such as cleaning the wound, applying medication, and dressing the wound. The LPN confirmed during an interview that she did not follow infection control standards, which increased the risk of infection for the resident. The facility's policy requires clean gloves to be applied, old dressings to be removed and discarded, and new gloves to be used when cleansing the wound and applying medication.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff, including Registered Nurses, Licensed Nurses, and Nursing Assistants, as required by federal and state regulations. This deficiency was observed during multiple visits, where no nurse staffing information was prominently displayed and accessible for patients, visitors, and staff. During interviews, the Administrator and the Director of Nursing (DON) acknowledged the issue, citing problems with the Velcro not sticking to the wall and the glass case not holding the sheets. Instead, the staffing sheets were kept in a box beside the business office door and in a drawer in the DON's office, making them inaccessible for review. This failure had the potential to affect all 59 residents residing at the facility and any visitors.
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.
Trusted by long-term care providers and associations.
