Sunset Villa Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Roswell, New Mexico.
- Location
- 1515 South Sunset Avenue, Roswell, New Mexico 88203
- CMS Provider Number
- 325117
- Inspections on file
- 20
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sunset Villa Healthcare during CMS and state inspections, most recent first.
The facility did not report allegations of abuse and neglect to the State Agency within the required timeframe for three residents. Incidents included a CNA pulling a resident by the arm and making inappropriate comments, a resident left in a soiled brief without personal care, and a meal not being offered despite documentation stating it was refused. Required incident reports were not submitted promptly, and one incident was incorrectly dated.
The facility did not submit investigation summaries to the State Survey Agency within the required five working days following an alleged abuse incident involving a CNA and a resident, as well as a physical altercation between two residents. The Administrator confirmed the delays in reporting for both cases.
A CNA verbally abused a resident by making derogatory comments about her financial situation and physically yanked her arm while assisting her, causing the resident to feel rushed and embarrassed. The CNA had previously received training on abuse prevention and resident rights.
Three residents requiring assistance with ADLs, including bathing, did not consistently receive showers or baths as scheduled, with documentation showing multiple gaps of several days without evidence of being offered or assisted with bathing. Interviews confirmed that residents did not receive the expected level of care, and the administrator acknowledged the shower schedule was not followed.
A resident with multiple diagnoses, including Alzheimer's and severe dementia, was left on the floor for approximately three hours after a fall due to staff failing to conduct timely rounds. The resident's daughter, monitoring via a camera, alerted the facility, leading to staff assistance. The facility's policy required rounds every two hours, which were not completed, resulting in neglect.
The facility failed to implement an ongoing infection prevention and control program, as observed by signs of enhanced barrier precautions on several room doorways. The Infection Preventionist (IP) confirmed the lack of documentation for an annual review of infection monitoring, attributing the failure to the previous IP not completing these duties. This deficiency potentially affects all 96 residents in the facility.
The facility failed to implement a comprehensive antibiotic stewardship program, as the Infection Control Committee did not regularly review infections or monitor antibiotic usage patterns. The Infection Preventionist confirmed the absence of documentation for ongoing monitoring and an annual review, attributing the lapse to the previous IP's inaction. This deficiency could potentially affect all 45 residents.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan lacked interventions for a wander guard and dementia care, another's omitted hydration support and hospice services, and a third's catheter care plan was delayed by 38 days. These oversights were confirmed by the DON, highlighting gaps in care planning.
The facility failed to update the care plans for two residents regarding their pain medication management. One resident had an order for oxycodone, and another for a fentanyl patch, but their care plans did not include necessary details such as monitoring for pain, non-pharmacological interventions, or the effectiveness of the medication. The DON confirmed these omissions.
A resident who signed a consent form for the influenza vaccine did not receive the vaccination. The EHR showed the last flu shot was given over a year prior, and despite consenting to a new vaccination, the resident did not receive it. The DON confirmed the oversight but could not explain why the vaccine was not administered.
The facility failed to offer COVID-19 vaccinations to four residents, as their EHRs lacked documentation of vaccine offers or administration. The DON confirmed the absence of evidence, despite the facility's policy to follow CDC guidelines for COVID-19 prevention.
A resident with cognitive impairment and multiple diagnoses was observed dressing in her room in view of the dining area, compromising her privacy. The resident required assistance with dressing, as noted in her care plan, but was left exposed to staff and other residents.
A facility failed to maintain a homelike environment for a resident by not repairing a damaged wall and broken blinds in the resident's room. The resident reported the issue to maintenance but received no response. An observation confirmed the poor condition, and the Maintenance Director acknowledged the need for repairs.
The facility failed to create accurate baseline care plans for two residents, one with a catheter and another with a UTI, leading to potential gaps in immediate care. The Director of Nursing confirmed the omissions, emphasizing the need for accurate care plans to ensure proper resident care.
A resident with multiple diagnoses, including cognitive impairment, was observed struggling to dress herself without staff assistance, despite her care plan indicating the need for supervision and assistance. This incident highlights a deficiency in the facility's adherence to the care plan, potentially affecting the resident's dignity and health.
A resident with severe dementia and other medical conditions did not receive adequate hydration support in a facility. The resident was not consistently offered drinks by staff, and fluid intake was not properly documented or monitored. The care plan indicated total dependence on staff, yet no hydration support or interventions were in place. The Director of Nursing confirmed the lack of necessary supports for the resident's hydration needs.
The facility failed to label medications with a proper open date or expiration date, as observed with three opened bottles of generic throat spray in the Medication Storage room. An LPN confirmed the bottles were opened without a labeled open date and had unreadable expiration dates, making it impossible to determine their expiration. The DON confirmed that opened medications should be labeled correctly.
Two residents at a facility experienced falls due to inadequate supervision and failure to follow safety protocols. One resident, a moderate fall risk, was left unsupervised in the restroom, resulting in a fall and a brain bleed. Another high fall risk resident fell during a therapy session without a gait belt and was not assessed by a nurse immediately after. Both incidents highlight lapses in adhering to fall prevention protocols.
The facility failed to lock a medication cart near the nurse's station, leaving it unattended and accessible to residents. The DON confirmed this did not meet facility expectations, as carts should be locked when not in use.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, leaving critical sections such as Nursing Services, Nutritional Services, and Activities blank. This was confirmed by facility staff, indicating a lapse in ensuring immediate care needs are met.
The facility failed to maintain a current, comprehensive care plan for a resident, as all items in the care plan were canceled. This was confirmed by a Regional Nurse, indicating a lack of an updated care plan to address the resident's needs.
A resident with a complex medical history informed a nurse she thought she was having a stroke, but no immediate action was taken. Later, the resident showed significant weakness during a transfer, which was not adequately assessed. The resident became unresponsive and hypoxic several hours later, leading to a delay in treatment and her eventual death in the hospital.
A facility failed to provide adequate supervision and preventive measures for a resident with dementia at risk of elopement. The resident was found outside the facility, and at the time, there was no operational Wander Guard system. Subsequent evaluations identified the resident as an 'Imminent Risk,' and the resident was later equipped with a functional Wander Guard monitor.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency within the required twenty-four-hour timeframe for three out of five residents reviewed. Specifically, one incident involved a CNA pulling a resident by the arm and making derogatory comments about her financial situation while assisting her into a sitting position. Another incident involved a CNA assisting a resident to bed while leaving them in a soiled adult brief and not providing necessary personal care. Additionally, there was an allegation that a CNA falsely reported a resident refused a meal when the meal was never offered. Record reviews and interviews confirmed that the initial incident reports for these events were not submitted to the State Agency within the mandated timeframe, with one incident's date of occurrence also being incorrectly documented.
Failure to Timely Report Investigation Results to State Survey Agency
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse or neglect to the State Survey Agency within five working days of the incidents, as required. Specifically, an incident occurred in which a Certified Nurse Aide allegedly pulled a resident by the left arm while assisting her into a sitting position, and the investigation summary for this event was submitted six working days after the incident. Additionally, a resident-to-resident altercation involving physical assault was not reported within the required timeframe. The Administrator confirmed that the investigation summaries for both incidents were not submitted to the State Survey Agency within five working days.
Verbal Abuse and Rough Handling by CNA
Penalty
Summary
A certified nurse aide (CNA) was verbally abusive to a resident by making fun of her financial situation and telling her that a driver would take her to another facility because she could not afford her bills. The CNA also yanked the resident by her left arm while assisting her into a sitting position, which made the resident feel rushed and embarrassed. The resident reported that she did not like being rushed and felt embarrassed by the CNA's comments and laughter regarding her finances. Review of the CNA's training file confirmed that the CNA had received training on abuse, neglect, exploitation, and resident rights prior to the incident.
Failure to Provide Scheduled ADL Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL), specifically bathing or showering, for three residents who required varying levels of support. Documentation and interviews revealed that these residents did not consistently receive showers or baths according to the facility's established schedule. In several instances, there were gaps of multiple days where no evidence was found that residents were offered or assisted with bathing, and in some cases, residents reported not receiving a shower since admission except for a single occasion. One resident, admitted with fractures and requiring substantial to maximal assistance, was scheduled for showers three times a week but only received one documented shower during the review period. The resident confirmed not being assisted with showers as expected and expressed that even if one shower was provided, it was insufficient. Another resident with heart failure and muscle atrophy, also requiring significant assistance, was scheduled for showers on alternate days but experienced periods of up to seven days without documentation of being offered or assisted with a bath or shower. This resident also reported inconsistencies in receiving scheduled showers. A third resident, with dementia and failure to thrive, required partial to moderate assistance and was scheduled for showers three times a week. Documentation showed only three showers provided in the month, with several refusals noted, but also multiple periods of up to seven days with no documentation of being offered or assisted with bathing. The facility administrator confirmed that the shower schedule was not followed for these residents, as reflected in the facility's records.
Neglect Incident: Resident Left on Floor for Hours After Fall
Penalty
Summary
The facility failed to prevent neglect for a resident who was not checked on timely by the staff, resulting in the resident lying on the floor for approximately three hours after a fall. The resident, who had multiple diagnoses including Alzheimer's disease, bipolar disorder, severe dementia with behavioral disturbance, cognitive communication deficit, and essential hypertension, was admitted to the facility with a care plan indicating a risk for falls due to confusion, deconditioning, and poor safety awareness. On the night of the incident, the resident's daughter, who had installed a camera in the resident's room, observed her father fall at approximately 8:45 pm and remain on the floor until she called the facility at 12:09 am to alert them. The facility's policy required nursing staff to conduct rounds at least every two hours, but this was not adhered to, as evidenced by the video footage and the resident's daughter's account. The Director of Nursing acknowledged that the resident lying on the floor for over three hours did not meet the facility's expectations, as staff should have checked on the resident at least every two hours. The failure to complete rounds timely and ensure the resident's safety led to the neglect incident, as the staff did not enter the room until after being notified by the resident's daughter.
Failure to Implement Ongoing Infection Control Program
Penalty
Summary
The facility failed to develop and implement an ongoing infection prevention and control program, which is essential for preventing, recognizing, and controlling the onset and spread of infections. This deficiency was identified during a survey when signs indicating enhanced barrier precautions were observed on the doorways of several rooms. A review of the facility's Infection Prevention and Control Program Policy revealed that the Infection Preventionist (IP) is responsible for coordinating the development and monitoring of infection control policies and procedures, as well as reporting compliance information to the Administrator and the Infection Control Committee. During an interview, the IP confirmed the absence of ongoing documentation or evidence to support an annual review of infection monitoring. The IP acknowledged that the facility had not continuously implemented an ongoing infection prevention and control program prior to October 2024 due to the previous IP not fulfilling these duties. This failure has the potential to affect all 96 residents living in the facility, as identified by the census provided by the Administrator.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is essential for optimizing infection treatment and minimizing adverse events related to antibiotic use. The deficiency was identified during a survey, where it was found that the Infection Control Committee (ICC) did not regularly review infections or monitor antibiotic usage patterns as required by the facility's policy. The policy, last revised in June 2020, mandates that the ICC should review microbial culture results, resistant organisms, alerts, and antibiograms for trends of resistance. However, there was no documentation to support that these activities were being conducted regularly. During an interview, the Infection Preventionist (IP) confirmed the absence of ongoing monitoring documentation for antibiotic usage patterns and acknowledged that an annual review of the Antibiotic Stewardship Program had not been completed. The IP attributed this lapse to the previous IP's failure to perform these duties before October 2024. Since taking over, the current IP has only monitored infections for four months, leaving an eight-month gap without continuous implementation or review of the program. This lack of documentation and consistent monitoring could potentially affect all 45 residents in the facility.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #5's care plan lacked interventions for the use of a wander guard and did not address the care required for his severe dementia diagnosis. This oversight was confirmed by the Director of Nursing (DON) during an interview, highlighting a gap in the care plan that could result in staff being unaware of the resident's needs. Resident #24's care plan was also found to be lacking, as it did not include interventions for hydration support, dementia care, or hospice services. The resident's daughter, who has a camera in the resident's room, reported that staff did not offer fluids as promised, which was not addressed in the care plan. The DON confirmed these omissions, acknowledging that the care plan was not comprehensive and did not meet expectations. For Resident #34, the care plan for catheter care was not developed or implemented until 38 days after admission, despite the resident having a catheter in place upon arrival. This delay in care planning was confirmed by the DON, who stated that the care plan did not meet her expectations. These deficiencies indicate a failure to provide timely and appropriate care planning for residents with specific medical needs.
Failure to Revise Pain Management Care Plans
Penalty
Summary
The facility failed to revise the care plans for two residents regarding their pain medication management. Resident #5 was admitted to the facility and had a physician order for oxycodone to be administered every six hours as needed for pain. However, the comprehensive care plan for Resident #5, last revised on January 31, 2025, did not include the use of pain medications, monitoring for pain, non-pharmacological interventions, or the effectiveness of pain medication use. The Director of Nursing confirmed that the care plan was not updated to include these aspects of pain management. Similarly, Resident #24 had a physician order for a fentanyl transdermal patch to be administered every three days. The comprehensive care plan for Resident #24, last revised on October 23, 2024, did not include the order for the fentanyl patch or interventions for monitoring pain, non-pharmacological interventions, or the effectiveness of pain medication use. The Director of Nursing confirmed that the care plan for Resident #24 was not revised to include pain medication management, which was necessary.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to ensure that a resident who had completed and signed a consent form for the influenza vaccine actually received the vaccination. The record review of the resident's Electronic Health Record (EHR) indicated that the last influenza vaccine was administered on 09/21/22, and the resident signed a consent for the influenza vaccine on 11/28/24. However, the EHR did not show that the resident received the vaccination after consenting. During an interview with the Director of Nursing (DON), it was confirmed that the resident had not yet received the influenza vaccination after providing consent, and the DON was unable to confirm why the vaccination had not been administered.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to four residents, as identified in the report. The Electronic Health Records (EHR) for these residents did not contain any documentation indicating that the COVID-19 vaccine was offered or administered. Specifically, Resident #7 and Resident #10's records lacked any COVID-19 vaccine forms, while Resident #9 and Resident #14 had not been offered the vaccine since their last recorded vaccinations in 2022. Interviews with the Director of Nursing (DON) confirmed the absence of evidence in the EHRs for these residents. The facility's COVID-19 Program Policy, revised in May 2021, aims to prevent the spread of COVID-19 by following CDC recommendations. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and offering of the COVID-19 vaccine to the residents. The CDC recommends that individuals in long-term care settings receive the COVID-19 vaccine, yet the facility's failure to offer the vaccine to these residents represents a significant oversight in their infection control and prevention efforts.
Failure to Ensure Resident Privacy During Dressing
Penalty
Summary
The facility failed to ensure personal privacy for a resident while dressing in her room, leading to a deficiency in maintaining confidentiality and dignity. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, a degenerative disease of the nervous system, and altered mental status, was observed standing in her room wearing only a disposable adult brief and a t-shirt while pulling up her pants. This occurred in full view of the main dining area, where staff and other residents could see her. The resident's care plan indicated she required supervision and assistance with dressing, highlighting a lapse in providing the necessary support to maintain her privacy.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident by not repairing the wall and the blinds in his room. During an interview, the resident pointed out the sliding glass door in his room, which had several broken and missing blinds, and mentioned that he had requested maintenance to fix them but had not received any response. The resident indicated that the blinds had been in disrepair for months, although he could not recall the exact duration. An observation of the resident's room revealed a section of the wall by the bed, measuring approximately six feet by three feet, with paint that was scraped and peeling. Additionally, the sliding glass door had several broken and missing blinds. The Maintenance Director confirmed the room's poor condition and acknowledged the need for repairs, stating that he would look into ordering new blinds.
Inaccurate Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to create accurate baseline care plans for two residents, leading to potential gaps in their immediate care needs. One resident was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, a urinary tract infection (UTI), bladder-neck obstruction, and benign prostatic hyperplasia. Despite being admitted with a catheter, the baseline care plan did not document the presence of the catheter or any necessary interventions. This oversight was confirmed by the Director of Nursing (DON), who acknowledged the omission and stated that the expectation is for all baseline care plans to contain accurate information to ensure residents receive the care they need. Another resident was admitted with a UTI, type 2 diabetes, and acute kidney failure. The resident reported frequent UTIs and confirmed being admitted with one. However, the baseline care plan lacked any interventions for the UTI. This deficiency was also confirmed by the DON, who reiterated the expectation for baseline care plans to accurately reflect residents' needs. The absence of these critical details in the care plans could lead to inadequate care and potential adverse events for the residents.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required help with dressing. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, a degenerative disease of the nervous system, and altered mental status, was observed struggling to dress herself without staff assistance. Despite having a care plan indicating the need for supervision and assistance with dressing, the resident was left to dress herself in full view of the dining area, highlighting a lapse in the facility's adherence to the care plan. During a dining observation, the resident was seen attempting to put on her pants without success, indicating a need for assistance as outlined in her care plan. The resident's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment, which further underscores the necessity for staff support. The lack of assistance in this instance is a clear deficiency in the facility's provision of care, potentially affecting the resident's dignity and health.
Failure to Maintain Adequate Hydration for a Dependent Resident
Penalty
Summary
The facility failed to maintain adequate hydration for a resident, identified as R #24, who was dependent on staff for all self-care activities. The resident, who had severe dementia with behavioral disturbances and other medical conditions, was not offered drinks consistently when staff entered his room, as reported by his daughter and Power of Attorney. The facility's records showed that the resident's fluid intake was not documented or monitored daily, and there were no recommendations or orders for the amount of fluid the resident should have daily. The care plan indicated total dependence on staff, yet the facility did not have any hydration support or interventions in place. The documentation survey report for January 2025 revealed that on 22 out of 31 days, the resident did not receive the minimum amount of fluids recommended by CMS. Specific instances of inadequate fluid intake were documented, with some days showing no fluid intake recorded at all. The Director of Nursing confirmed that the resident did not have any supports or interventions to assist with hydration needs, acknowledging that such supports were necessary given the resident's state of dependence.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled with a proper open date or expiration date, which is a deficiency likely to negatively impact the health of all residents. During an observation of the Medication Storage room, three opened bottles of generic throat spray were found without a labeled open date and with unreadable expiration dates. An LPN confirmed that the bottles were opened, the expiration dates were unreadable, and no open date was written on them, making it impossible to determine when they were opened or their expiration. The Director of Nursing also confirmed that opened medications should be labeled correctly with a readable open date and expiration date.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to prevent accidents for two residents, both of whom were at risk for falls. The first resident, who had a history of repeated falls and was considered a moderate fall risk, was left unsupervised in the restroom. Despite being aware of the resident's fall risk, the staff did not provide the necessary supervision, resulting in the resident falling and sustaining a head injury that led to a brain bleed. Interviews with the resident's family and hospice nurse confirmed that the resident was left alone, contrary to the family's instructions and the facility's protocol. The second resident, who was identified as a high fall risk, experienced a fall during a therapy session. The Occupational Therapy Aide did not use a gait belt, as required by the facility's protocol, and failed to notify a nurse for an assessment after the fall. Instead, the resident was assisted off the ground and taken to lunch without a proper evaluation. The resident later required medical attention for symptoms that developed after the fall, including a headache and emesis. Both incidents highlight a failure to adhere to established protocols for fall prevention and post-fall assessment. The staff interviews revealed a lack of consistent application of safety measures, such as the use of gait belts and immediate nurse assessments following falls. These deficiencies contributed to the residents' injuries and subsequent hospital treatments.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all medication carts were locked while not in use, which had the potential to affect all 19 residents residing in rooms 100-111. During a random observation, a medication cart located near the nurse's station was found unlocked, with no staff present in the area. Residents were observed in the vicinity of the unlocked cart. In an interview, the Director of Nursing confirmed the cart was unlocked and unattended, which did not meet the facility's expectations, as medication carts should be locked when not actively being used by a nurse.
Incomplete Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to create accurate baseline care plans within 48 hours of admission for two residents, which is a necessary step to ensure proper care. For the first resident, the baseline care plan was incomplete, with only the Social Services section filled out, while Nursing Services, Rehabilitative Services, Nutritional Services, and Activities sections were left blank. This was confirmed by both the Regional Clinical Consultant and the Minimum Data Set Coordinator. Similarly, the second resident's baseline care plan was missing entries in the Nursing Services, Nutritional Services, and Activities sections, as confirmed by the Regional Nurse. These omissions could likely result in a decline in the residents' conditions due to staff not being aware of the care residents need.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive person-centered care plan for a resident, identified as R #2, who was admitted to the facility on an unspecified date. A review of R #2's care plan, dated 04/24/24, revealed that all items were listed as canceled, indicating the absence of a current care plan. This deficiency was confirmed during an interview with the Regional Nurse on 06/06/24, who acknowledged that there was no current, updated care plan for R #2 due to the cancellation of all items in the existing care plan.
Failure to Identify and Respond to Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who had a complex medical history including acute and chronic respiratory failure, Type 2 Diabetes Mellitus, morbid obesity, and other conditions, informed a nurse that she thought she was having a stroke. Despite this, the nurse did not contact the physician or take further immediate action. Later, the resident demonstrated significant unexplained weakness during a transfer, which was not adequately assessed as a change in condition by the staff. Several hours later, the resident became unresponsive and hypoxic, leading to a delay in treatment and her eventual death in the hospital emergency room. The nursing progress notes revealed that the resident had reported feeling like she was having a stroke, but the nurse did not observe any immediate signs of a stroke and did not contact the physician. Later in the day, the resident was unable to assist in her transfer from a wheelchair to bed, and staff had to use a hoyer lift to complete the transfer. Despite the resident's significant weakness, the nurse did not check her vital signs or consider it a change in condition. The resident was later found unresponsive by her husband, with an oxygen saturation level of 65%, and was subsequently transferred to the hospital where she was intubated and later expired. Interviews with staff, including the CNA and LPN involved in the resident's care, confirmed that the resident had shown signs of significant weakness and fatigue, but these were not adequately assessed or reported as changes in condition. The Director of Nursing and Assistant Director of Nursing both acknowledged that the staff should have recognized these signs as changes in condition and taken appropriate actions, including notifying the physician and possibly sending the resident to the hospital earlier. The failure to do so likely contributed to the delay in treatment and the resident's subsequent death.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and preventive measures for a resident at risk of elopement. The resident, diagnosed with dementia, exhibited wandering behavior and was identified as an elopement risk. Despite this, the resident's Elopement Risk Evaluation scored them as 'No Risk.' On one occasion, the resident was found outside the facility in the parking lot, indicating a lapse in supervision. At the time of the incident, the facility did not have an operational Wander Guard system in place to prevent such occurrences. Subsequent evaluations of the resident indicated an 'Imminent Risk' for elopement, and the resident was later equipped with a Wander Guard monitor. Observations confirmed that the Wander Guard system was functional and that the resident wore the device. Interviews with staff corroborated the resident's elopement risk and the use of the Wander Guard system as a preventive measure.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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