Belen Meadows Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Belen, New Mexico.
- Location
- 1831 Camino Del Llano, Belen, New Mexico 87002
- CMS Provider Number
- 325068
- Inspections on file
- 28
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Belen Meadows Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and major depression had an unwitnessed fall in her room that resulted in a swollen hand. Staff performed an assessment, notified a provider via Telehealth, and obtained an x-ray to rule out injury, which showed no fracture or dislocation. Despite the facility’s abuse prohibition policy requiring immediate reporting of alleged injuries and injuries of unknown source to the State Agency, the DON and ADM acknowledged that this unwitnessed fall with potential injury met reporting criteria but was not reported.
The facility did not replace the ice machine filters by the recommended date, as observed on two occasions. Both the District Manager and Maintenance Director confirmed the filters were overdue for replacement and acknowledged responsibility for this task.
The facility did not ensure proper infection control practices when laundry staff repeatedly found used shaving razors in dirty towels, with incidents not reported to the Infection Control Preventionist or DON. Additionally, the Water Management Program lacked procedures, control limits, monitoring protocols, and interventions to minimize Legionella risk, and facility leadership was unaware of these deficiencies.
A resident with a chronic sacral pressure ulcer repeatedly refused wound care during the night shift, expressing a preference for daytime care. Despite these requests, staff continued to attempt wound care at night, and there was no documentation of any change to the care plan or physician orders to accommodate the resident's wishes. Nursing notes and interviews confirmed the resident's refusals and preferences, but the facility did not adjust care practices or document reasons for missed wound care.
Staff did not maintain a safe and homelike environment, as evidenced by burnt-out lights, damaged walls, and missing blinds in the dining area, as well as broken fixtures, water leaks, foul odors, and pest infestations in several resident rooms and bathrooms. Residents reported ongoing maintenance issues and discomfort, while maintenance staff acknowledged responsibility but did not complete necessary repairs.
Surveyors found that staff administered medications with an error rate of 8.6%, exceeding the 5% threshold. Errors included a resident receiving levothyroxine and apixaban outside of prescribed timeframes, and another resident being given Artificial Tears without an active provider order. CMAs cited workload and misunderstanding of order status as contributing factors, and the DON confirmed that medications should only be given as ordered and within specified timeframes.
A treatment cart containing wound care supplies and medical tools was left open and unattended by a nurse, making its contents accessible. The DON confirmed that all treatment carts are expected to be locked when not attended by staff.
A resident with diabetes, morbid obesity, and legal blindness was not provided with meals that matched her documented vegetarian diet preference, including no eggs or meat. Despite repeated reminders to staff, the resident continued to receive meals containing meat, such as pork sandwiches, and was left hungry. Facility records showed conflicting diet orders, and staff interviews confirmed the resident's dietary needs were not consistently met.
Two residents experienced deficiencies in medical record-keeping, including discrepancies in documentation of fall events and missing entries in ADL flow sheets. The Corporate Nurse and DON acknowledged issues with inaccurate records and incomplete documentation, with contributing factors including staff access to electronic records and short duration of stay.
A resident with a documented diagnosis of major depressive disorder and related symptoms was not accurately identified as having a mental illness on the PASARR Level I Identification Screening. The facility's records and staff interview confirmed that the screening failed to reflect the resident's mental health diagnosis, contrary to policy and assessment findings.
A resident with dementia and a history of left femur fracture experienced a fall resulting in increased pain and visible distress. Despite escalating pain levels and abnormal physical findings, there was a significant delay in obtaining x-rays and transferring the resident to the hospital. Staff interviews revealed lapses in communication and timely intervention, leading to prolonged pain before the resident received appropriate care.
A resident with multiple health conditions was found sleeping on a deflated alternating air mattress, despite provider orders and care plans specifying its use. Staff interviews confirmed that nursing staff were responsible for checking such equipment, but the mattress was not properly inflated at the time of observation.
Staff did not date the oxygen humidifier bottle for a resident with CHF and anemia, despite facility policy and provider orders requiring dating and weekly replacement of oxygen equipment. The undated humidifier was observed in use, and both a nurse and the DON acknowledged the requirement for proper labeling and replacement.
Staff did not dispose of a completed medication after a resident's treatment ended, leaving an opened bottle of artificial tears in the medication cart and failing to document its removal as required by facility policy. The nurse responsible for medication destruction did not receive the medication, and the DON confirmed that completed medications should not remain in carts.
A resident did not receive required annual dental care, with the last documented dental visit occurring nearly two years prior. Although there was an order for a dental appointment, there was no evidence the appointment occurred, and the order was discontinued. The facility relied primarily on the driver to track and schedule dental appointments, while other staff were unaware of the missed care. The DON stated that the responsibility should have been shared by the IDT.
A resident with a history of falls and limited mobility was observed using a wheelchair with a detached back bar, which had been broken for an extended period. An LPN noticed the issue and verbally reported it but did not document it, and the PT confirmed the wheelchair was unsafe and missing necessary parts. The resident continued to use the unsafe wheelchair until the issue was addressed.
The facility failed to provide written notification to residents and their representatives about room changes due to a flooding event. Although families were informed by phone, there was no written documentation provided, affecting eight residents. The Director of Nursing confirmed the lack of written notifications, which is required for room changes.
The facility failed to document medication refrigerator temperatures, as required, for several days. This was discovered through record review and observation, revealing that insulin and other medications requiring refrigeration were stored without proper temperature monitoring. The DON confirmed that staff must check and document temperatures twice daily to ensure they remain within the necessary range.
The facility failed to serve meals according to dietary meal tickets for three residents. One resident did not receive double portions as required, another had multiple missing items and incorrect meals, and a third reported frequent mismatches between the menu and served food. The Regional Dietary Manager confirmed these issues.
A resident's bathroom doorknob was broken for several weeks, preventing access to the restroom. Despite a work order being submitted, the repair was not completed, and the facility's administrator was unaware of the status. The resident, who was continent and able to toilet independently, had informed CNAs about the issue.
The facility failed to maintain an accurate care plan for a resident, including conflicting statements about smoking status. The care plan initially prohibited smoking, then allowed supervised smoking, despite the resident having no history of smoking. The DON confirmed the inaccuracies during an interview.
A facility failed to revise a resident's care plan accurately, which continued to indicate an active UTI despite the resident not having one since February. The care plan, dated June, should have reflected the resident's risk for developing UTIs. The DON confirmed the oversight during an interview.
The facility failed to obtain wound care orders for a resident with pressure sores, leading to confusion and lack of documented care. Despite the wound care nurse documenting the sacral wound and an order being placed, the treatment administration record did not reflect this, causing inconsistencies in wound care management.
Failure to Report Unwitnessed Fall With Potential Injury to State Agency
Penalty
Summary
The facility failed to report an alleged incident involving an unwitnessed fall with potential injury to the State Agency as required by its Abuse Prohibition policy. The policy, revised on 11/14/25, prohibits neglect and requires immediate reporting, investigation, documentation, and follow-up of alleged injuries, including injuries of unknown source. It directs the facility to initiate an investigation within 24 hours of receiving information about an injury or suspected neglect, document interviews and findings, notify the physician and resident representative, and submit findings of completed investigations within five days to the State Agency. Record review showed that a resident with dementia, muscle weakness, and major depression experienced an unwitnessed fall in her room, after which staff documented a swollen left hand. A Telehealth provider was contacted and ordered an x-ray of the hand, which later showed no fracture or dislocation. The DON stated that an unwitnessed fall with hand swelling and an x-ray to rule out injury met the criteria for reporting to the State Agency due to the potential for injury. The Administrator confirmed awareness of the fall and acknowledged that the incident should have been reported to the State Agency but was not, resulting in the failure to follow the facility’s abuse/neglect reporting requirements.
Failure to Replace Ice Machine Filters Timely
Penalty
Summary
The facility failed to ensure timely replacement of the filters on the ice machine, as observed on two separate occasions. The filters displayed a replacement date of 04/24/25, and instructions on the filters indicated they should be changed at least once per year. Despite this, the filters had not been replaced by the time of the second observation. During interviews, the District Manager confirmed that the Maintenance Director was responsible for changing and ordering the filters, and the Maintenance Director acknowledged that the filters needed to be changed.
Deficient Infection Control in Laundry Handling and Legionella Water Management
Penalty
Summary
The facility failed to follow proper infection control practices in two key areas: handling of laundry contaminated with used sharps and implementation of an adequate Water Management Program (WMP) to minimize the risk of Legionella. Observations revealed that laundry staff found used shaving razors in dirty towels brought to the laundry room, and these razors were subsequently placed in sharps disposal containers. The laundry technician reported finding razors in the laundry but could not recall when or to whom the incidents were reported. Both the Infection Control Preventionist and the Director of Nursing were unaware of these incidents, indicating a lack of communication and reporting regarding the presence of sharps in laundry. Facility policy on needle handling and sharps injury prevention did not address the risk of sharps contaminating linen or provide guidance on preventing such occurrences. Additionally, the facility's WMP was found to be inadequate in several areas. The policy lacked procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system, did not specify control limits or parameters, and failed to include monitoring procedures or environmental testing protocols for Legionella. There were also no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case. During interviews, facility leadership acknowledged that the WMP was reviewed annually but were unaware of its deficiencies in addressing Legionella risk.
Failure to Honor Resident's Preference for Wound Care Timing
Penalty
Summary
The facility failed to honor a resident's preference regarding the timing of wound care. The resident, who had quadriplegia, chronic pain, anxiety, depression, and a chronic sacral pressure ulcer, had physician orders for wound care to be performed twice daily on both day and night shifts. Documentation showed that wound care was frequently attempted during the night shift, but the resident repeatedly refused, stating a preference for wound care to be done during the day. Despite these refusals and the resident's clear requests, staff continued to attempt wound care at night, and there was no documentation of any adjustment to the care plan or physician orders to accommodate the resident's wishes. Nursing progress notes indicated multiple instances where the resident refused wound care at night and requested it be performed during the day. Interviews with the DON and Unit Manager confirmed awareness of the resident's refusals and preferences, but there was no evidence in the medical record, care plan, or orders that the timing of wound care was discussed or changed in response. Additionally, there was a lack of documentation explaining missed wound care opportunities or refusals on certain days.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Staff failed to maintain a safe, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies in the dining room and resident rooms. Observations revealed that the dining room had several burnt-out fluorescent and chandelier bulbs, scuffed walls with missing paint, and window blinds with missing slats. The Maintenance Director acknowledged responsibility for these areas and confirmed that the lights, walls, and blinds should have been maintained in good condition. In resident rooms and bathrooms, issues included non-functional hot water faucets, broken and uneven floor tiles, slow-draining sinks, standing water, foul odors, cracked windows, broken bed footboards, and partially detached window screens. Residents reported water leaks during rain, persistent foul odors, and unaddressed maintenance requests. The Maintenance Director was aware of some issues but stated repairs were not completed. Additionally, one resident's bathroom was repeatedly observed to have a significant presence of flies over several days, with the resident confirming the ongoing issue and expressing discomfort. Certified Nurse Aide (CNA) staff stated they would report hazards but were unaware of the specific problems observed, including the presence of flies. The Maintenance Director was not aware of the fly infestation and agreed the issue should have been addressed. These failures affected both common areas and multiple resident rooms, impacting the environment and comfort of the residents.
Medication Error Rate Exceeds 5% Due to Timing and Order Lapses
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in an observed error rate of 8.6% during the survey. For one resident with a history of venous thrombosis, embolism, and hypothyroidism, a Certified Medication Aide (CMA) administered levothyroxine and apixaban outside of the prescribed timeframes. Levothyroxine was not given 30 to 60 minutes before breakfast as ordered, and apixaban was not administered within the specified two-hour window. The CMA attributed the late administration to being assigned to two resident halls, which delayed medication delivery. The resident had already eaten breakfast before receiving the morning medications, contrary to the provider's orders and facility policy. In another instance, a different CMA administered Artificial Tears to a resident who exhibited redness and irritation around the eyes. However, the order for Artificial Tears had expired, and the medication was given without an active provider order. The CMA believed there was an active order but acknowledged that all medications require a current order before administration. The Director of Nursing confirmed that medications should not be administered without an active order and that it is the responsibility of both the CMAs and nurses to ensure orders are up to date before giving any medication.
Unattended and Unlocked Treatment Cart Exposes Medical Supplies
Penalty
Summary
Staff failed to secure a treatment cart on the 200 Unit, leaving the top drawer open and unattended while staff were away from the area. Observations revealed that the cart contained wound care dressings, wound cleanser, tweezers, barrier cream, irrigation solution, and scissors, all of which were accessible due to the unlocked and open drawer. During interviews, a registered nurse acknowledged responsibility for the unlocked cart, stating he had stepped away to assist a resident and left the cart open. The Director of Nursing confirmed that staff are expected to lock all treatment and medication carts when not in attendance and reiterated that carts should never be left open and unattended.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
A deficiency occurred when a resident with a documented vegetarian diet preference, including no eggs and no meat, was not provided with meals that honored these preferences. The resident's admission diet order specified a regular vegetarian diet with no eggs or meat, but the care plan did not address these dietary restrictions. The Minimum Data Set (MDS) listed a diabetic diet, and the resident's lunch ticket indicated a regular diet, resulting in the resident being served meals containing meat, such as a pork sandwich. The resident reported consistently receiving meat with meals and only being able to eat the salad, leading to hunger and repeated reminders to staff about her dietary needs. Interviews with facility staff revealed confusion regarding the resident's diet orders, with multiple conflicting diet orders present in the system, including regular, consistent carbohydrate (CCHO), and vegetarian diets. The Dietary Director acknowledged the lunch ticket was incorrect and confirmed the resident should have been on a CCHO and vegetarian diet. The DON was unaware the resident had received the incorrect diet and stated the expectation was for all residents to receive the correct diet. The failure to provide the appropriate diet was confirmed through record review, observation, and interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with dementia, osteoarthritis, chronic pain, and a left femur fracture, discrepancies were found between the times documented in the electronic medical record and the facility's after-hours provider notification records regarding falls and subsequent provider notifications. The Corporate Nurse was unable to explain why the times did not match and acknowledged the documentation was not accurate. For another resident with quadriplegia, chronic pain, anxiety, and depression, significant gaps were identified in the Activities of Daily Living (ADL) flow sheet documentation. Missing entries were noted for bathing, bed mobility, dressing, hygiene, toileting, and eating over an eleven-day period. The DON confirmed that the documentation was unacceptable and attributed the issue in part to agency staff not having access to the electronic medical record, as well as the resident's short stay at the facility.
Failure to Accurately Complete PASARR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected a resident's diagnosis of major depressive disorder. According to the facility's policy, the Social Worker or designated staff are responsible for ensuring that all patients with mental disorders receive appropriate pre-admission screenings in accordance with federal and state regulations. Record review showed that a resident was admitted with diagnoses including liver disease, dementia, and major depressive disorder. The resident's Minimum Data Set (MDS) assessment documented symptoms consistent with depression, such as little interest or pleasure in activities, feeling down, poor appetite, low energy, trouble concentrating, and impaired memory and decision-making. The MDS also indicated a moderate cognitive impairment and specifically noted depression as a psychiatric/mood disorder. Despite this documented diagnosis and symptoms, the PASARR Level I Identification Screening completed for the resident indicated that the resident did not have a diagnosis of or a suspected mental illness. During an interview, the Social Services Director confirmed that the PASARR screening was incorrect and acknowledged that staff should have documented the resident's diagnosis of major depressive disorder.
Delayed Hospital Transfer Following Resident Fall with Injury
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, osteoarthritis, chronic pain, and a previous left femur fracture experienced a fall resulting in pain to the left shoulder and left groin area. Documentation showed that the resident's pain level increased from 2 to 5 on a 1-10 scale following the fall, and later reached a 7. Despite these symptoms and visible signs of distress, there was a significant delay in sending the resident to the hospital. X-rays were ordered but not completed until later in the day, eventually revealing a displaced fracture of the left femoral neck. The resident was not transferred to the hospital until after the abnormal x-ray results were obtained. Interviews with staff indicated confusion and lack of timely communication regarding the fall and the resident's condition. The unit manager and DON both stated they were not promptly notified of the incident, and an LPN expressed concern about the delay in assessment and intervention, noting that the resident was visibly in pain and her hip appeared abnormal. The delay in response and transfer to the hospital resulted in the resident remaining in pain for an extended period before receiving appropriate medical care.
Failure to Ensure Proper Inflation of Specialized Air Mattress
Penalty
Summary
A deficiency occurred when a resident with reduced mobility, legal blindness, type 2 diabetes mellitus, and morbid obesity was found sleeping on a deflated alternating air mattress. The resident's medical records and provider orders indicated the need for a specialty alternating air mattress to prevent or treat pressure injuries. The care plan also documented the use of this therapeutic mattress. However, during an observation, the mattress was found to be off, deflated, and without any power lights while the resident was in bed. Interviews with facility staff confirmed that the mattress was not properly inflated. An LPN acknowledged that the deflated mattress could cause entrapment or additional pressure wounds and stated that all nursing staff were responsible for checking resident care equipment. The DON also stated that it was her expectation for nursing staff to check equipment during daily rounds and that malfunctioning equipment could lead to negative outcomes for residents. The failure to ensure the resident's air mattress was properly inflated constituted the deficiency.
Failure to Date Oxygen Humidifier for Resident Receiving Respiratory Care
Penalty
Summary
Staff failed to properly maintain respiratory care equipment for a resident with congestive heart failure and anemia by not dating the oxygen humidifier bottle attached to the resident's oxygen concentrator. Facility policy required staff to label oxygen humidifiers with the date and replace disposable oxygen equipment every seven days. Provider orders also specified that oxygen components should be changed and labeled with the date and initials as needed and every week for infection control. During observation, the resident's oxygen humidifier was found undated, and interviews with nursing staff and the DON confirmed that the humidifier should have been dated and replaced according to policy and orders.
Failure to Dispose of Completed Medication as Required
Penalty
Summary
Staff failed to dispose of a completed medication for a resident after the prescribed treatment period had ended. Specifically, a resident had an order for artificial tears to be administered every two hours as needed for seven days, with a documented end date. After the order was completed, the medication was not removed from the medication cart as required by facility policy. During an observation, an opened and used bottle of artificial tears was found in the medication cart, and a Certified Medication Aide confirmed it belonged to the resident and should have been disposed of after the order ended. Further review showed that the facility's Medication Disposal Form did not include documentation of the completed artificial tears for this resident. Interviews with staff revealed that the nurse responsible for destroying discontinued medications did not receive the completed eye drops, and the DON stated that completed medications should not be kept in medication carts. The facility's policy requires discontinued medications to be promptly removed and documented, which was not followed in this instance.
Failure to Ensure Routine Dental Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental care as required. Record reviews showed that the resident had not received annual dental services, with the last documented dental visit occurring nearly two years prior. Although there was a provider order for a dental appointment, there was no documentation that the resident attended the appointment, and the order was later discontinued. Interviews with the resident confirmed that she had not received dental services in a while and was experiencing dental pain. Further investigation revealed that the facility's process for arranging dental appointments was unclear and inconsistently followed. The facility's driver was primarily responsible for tracking and scheduling dental appointments, with occasional input from social services and nurse managers. However, both the Social Services Director and Nurse Manager were unaware that the resident had missed annual dental appointments. The Director of Nursing clarified that the responsibility for arranging dental appointments should have been shared by the Interdisciplinary Team, not solely the driver.
Failure to Maintain Resident Wheelchair in Safe Condition
Penalty
Summary
A resident with a history of repeated falls, generalized muscle weakness, and a need for assistance with personal care was observed sitting in a wheelchair that was not maintained in safe operating condition. The back bar of the wheelchair was detached and hanging on one side, and the resident reported that the wheelchair had been broken for an extended period. The resident's care plan included interventions for assistance with activities of daily living, transfers, and mobility due to limited mobility. A Licensed Practical Nurse noticed the broken wheelchair and verbally informed the night nurse to notify therapy staff, but did not document the issue in the resident's progress notes. The Physical Therapist stated that staff were expected to submit a work order in the maintenance reporting system to repair the wheelchair and to place the resident in a different wheelchair until repairs were completed. The therapist confirmed that the wheelchair was missing a securing knob and was unsafe for use.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to inform residents and their representatives in writing about room changes due to a flooding event on the 200 wing. This affected eight residents who were moved without receiving written notification, including the reason for the change. Interviews with staff, including a Nurse Manager and the Director of Nursing (DON), revealed that while families were notified by phone, there was no written documentation provided to the residents or their representatives. The flooding began on 01/06/25, and residents were moved on the same day, but written notifications were not issued. Record reviews for several residents showed a lack of documentation regarding written notifications for room changes. For instance, one resident's medical record indicated that the resident was moved for safety reasons due to a plumbing issue, and the resident's Power of Attorney (POA) was notified by phone, but not in writing. Another resident's POA stated they were not informed of the room change and would have liked to know what was happening. The DON confirmed that while phone notifications were made, written notifications were not provided, which is a requirement for room changes.
Failure to Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that staff documented the medication refrigerator temperatures in the medication storage room. This deficiency was identified through record review, observation, and interviews. Specifically, the temperature log book for the medication #1 refrigerator, medication #2 refrigerator, and the specimen refrigerator showed that staff did not document temperature recordings for several dates, including the evening of 06/21/24, both morning and evening of 06/22/24, and both morning and evening of 06/23/24. During an observation on 06/24/24, it was noted that the medication storage room contained insulin and other medications requiring refrigeration. The Director of Nursing (DON) confirmed in an interview that staff are required to check and document the refrigerator and freezer temperatures twice daily to ensure they remain within the range of 36 to 46 degrees Fahrenheit, which is necessary to preserve temperature-controlled medications and specimens.
Failure to Serve Meals According to Dietary Meal Tickets
Penalty
Summary
The facility failed to ensure that residents received meals according to their dietary meal tickets, which are individualized descriptions of what staff should serve each resident. This deficiency was observed in three residents. One resident, who was supposed to receive double portions of all items, reported not getting enough food and was observed receiving only single portions, missing items like ice cream. The Regional Dietary Manager confirmed that the resident should have received double portions as per the meal ticket. Another resident provided meal tickets for May and June, noting missing items on each ticket and stating that complaints to the Dietary Manager had not resolved the issue. The resident's meal tickets showed multiple instances where items were missing from her food tray, including margarine, jelly, sugar, eggs, and more. Additionally, the resident was served meals that did not match the menu, such as receiving Mexican spiced chicken instead of the listed cowboy casserole. The Regional Dietary Manager acknowledged these discrepancies. A third resident reported that the food rarely matched the menu, leading her to obtain food from outside the facility.
Failure to Repair Resident's Bathroom Doorknob
Penalty
Summary
The facility failed to maintain a homelike environment by not repairing a broken doorknob for a resident's bathroom door. The deficiency was observed when the resident reported that the doorknob had been broken for several weeks, preventing access to the restroom. The resident, who was continent and able to toilet independently, had informed the CNAs about the issue. A work order for the doorknob replacement was submitted on 06/17/24, but the repair had not been completed by the time of the survey. The facility's administrator was unaware of the work order's status and mentioned that the maintenance director was unavailable due to a medical emergency during the period the work order was submitted.
Inaccurate Care Plan for Resident's Smoking Status
Penalty
Summary
The facility failed to ensure the comprehensive care plan was accurate for a resident reviewed for care plan accuracy. The care plan for the resident, dated June 4, 2024, included conflicting focus areas regarding smoking. Initially, the care plan stated that the resident may not smoke per a smoking evaluation initiated on February 26, 2023. However, it was later updated to indicate that the resident may smoke with supervision per a smoking evaluation initiated on May 5, 2023. During an interview on June 28, 2024, the Director of Nursing (DON) confirmed that the resident did not smoke and had no history of smoking, indicating that neither smoking statement should have been included in the care plan.
Care Plan Revision Deficiency for UTI Risk
Penalty
Summary
The facility failed to accurately revise the comprehensive care plan for a resident who was reviewed for care plans. The resident had an active urinary tract infection (UTI) and was at risk for sepsis, as noted in the care plan dated June 4, 2024, with the condition initially identified on February 10, 2024. However, a review of the resident's quarterly Minimum Data Set (MDS) dated May 22, 2024, indicated that the resident did not have a UTI in the past 30 days. During an interview on June 28, 2024, the Director of Nursing (DON) confirmed that the resident had a UTI in February 2024 but had not had one since. The DON acknowledged that the care plan should have been updated to reflect that the resident was at risk for developing UTIs, rather than indicating an active UTI.
Failure to Obtain Wound Care Orders for Resident with Pressure Sores
Penalty
Summary
The facility failed to meet professional standards of quality by not obtaining wound care orders for a resident with pressure sores. The resident was admitted with wounds on the left heel and right big toe, and later developed a stage II pressure wound on the sacrococcygeal area. Although the wound care nurse documented the sacral wound and an order was put in place on 12/16/23, the treatment administration record (TAR) did not reflect this order, leading to confusion and lack of documented wound care for the sacral wound. The Director of Nursing and the wound care nurse were unclear why the order did not appear on the TAR, despite conversations indicating that wound care was being completed. The issue was further complicated when a nurse found multiple wounds on the sacrum during a routine check and noted that the resident's tail bone was red and inflamed due to bowel movements. The Unit Manager confirmed that orders need to be in place for treatment to occur and that any discrepancies should be addressed by obtaining the necessary orders. A CNA also confirmed that the resident always had a dressing on the sacrum, but the lack of proper documentation and orders on the TAR led to inconsistencies in wound care management.
Latest citations in New Mexico
A clogged floor drain sink in a janitor room led to black, dirty water accumulating in the drain and overflowing into a hallway. A housekeeper reported that the drain, used for disposing of mop water and cleaning chemicals, had been clogged for some time and that she had informed her supervisor. The housekeeping supervisor stated she had submitted several work orders and that housekeeping staff had been attempting to unclog the drain themselves for months, while the maintenance director reported having no active work orders for the issue and indicated that such black water can carry harmful microorganisms. The administrator stated he expects staff to submit work orders and report issues promptly.
Surveyors found that a treatment cart containing drugs and biologicals on two units was left unlocked and unattended, with no staff present. An LPN confirmed the cart belonged to the treatment nurse, who was not on the unit at the time, and acknowledged that it was unlocked. A consultant nurse later stated that treatment carts are required to be locked when not in use.
A resident with impaired cognition had a family member designated as POA with authority over health care and related decisions. The POA, concerned about the resident’s care, repeatedly requested the resident’s medical records but was directed to Medical Records and required to complete written forms, unlike residents who could obtain records via oral request. The POA initially completed the form incorrectly and was told to redo it; the corrected paperwork was not submitted until after the resident’s death, at which point additional documentation was required. Staff, including MR personnel, acknowledged that the POA was authorized to act for the resident and that the resident lacked capacity to request records independently, yet the POA never received the records, resulting in a failure to allow the representative to exercise the resident’s rights.
A resident with impaired cognition and a low BIMS score had a family member designated as POA for health care and related decisions. The POA became concerned about the resident’s care and requested the resident’s medical records but did not receive them. Nursing notes documented the POA’s expressed frustration about still waiting for the records. The Medical Records staff required the POA to complete authorization paperwork twice, stated the first set was completed incorrectly, and reported that corrected paperwork was not returned until after the resident’s death, at which point additional documentation was required. Staff acknowledged that the POA was authorized to act on the resident’s behalf and that, unlike a resident’s own oral request, the POA’s request was not honored without extra paperwork, resulting in the POA never obtaining the records.
A resident’s care plan was not revised to include a family member’s request that a specific housekeeper have no contact with or provide care to the resident in a secure unit, despite the family reporting that this housekeeper had previously caused the resident to fall and had been verbally restricted from working around the resident by prior and current leadership. The housekeeping supervisor and the housekeeper confirmed that the housekeeper no longer worked in the secure unit or with the resident, but the MDS nurse reported she was never informed of this change and therefore did not update the care plan, and the ADON confirmed the care plan lacked this information.
The facility failed to maintain required postings of Ombudsman contact information in accessible areas for residents and their representatives. Surveyor observations found that Ombudsman information was not posted in the facility and that, when present, it was placed on the side of a refrigerator in the Activities Room rather than in a clearly visible location. The Administrator reported that Ombudsman posters had been removed to allow painting and were not re-posted afterward. This deficiency had the potential to affect all residents in the facility, as they and their representatives would not be aware of how to contact the Ombudsman about concerns.
The facility did not maintain the required 18 months of posted nurse staffing records. Surveyors observed that only the current day’s staffing information was posted in the lobby, and during interviews the new DON reported uncertainty about whether historical staffing records were kept. The Administrator later stated that the facility was trying, but unable, to access prior posted staffing information. As a result, residents and the public could not review the required historical nurse staffing data.
The facility did not consistently provide adequate evening and nighttime snacks to residents who requested them. A resident reported that snacks were rarely offered at night and that staff sometimes said none were available. Observation of the nourishment refrigerator showed minimal, often unlabeled items, while CNAs and the Activities Assistant described limited quantities of milk, yogurt, shakes, and sandwiches for multiple residents on each hall. The DM and DON confirmed that snacks were now restricted to those ordered by the RD, with no general snacks left accessible and no staff access to the kitchen at night, resulting in residents without prescribed snacks frequently being told there were not enough snacks and staff occasionally buying snacks themselves.
A resident with a history of cerebral infarction, dementia, and glaucoma did not receive ordered Dorzolamide HCI-Timolol Maleate eye drops after an LPN accidentally discontinued the medication in the system without a physician’s order. The MAR showed the drops were not administered because no active order was available, and nursing documentation later confirmed the facility had discontinued the eye drops without provider authorization. In interviews, the administrator and DON acknowledged that the medication had been stopped in error and that there was no physician order to discontinue it.
A resident with COPD, acute respiratory failure, pulmonary fibrosis, and recent hospitalization for UTI and sepsis returned from the hospital on palliative care with an order for continuous O2 at 2 L/min via nasal cannula. After arrival, staff removed the ambulance’s portable O2 and attempted to use the facility’s O2 concentrators, which were ineffective, while the resident was restless and grabbing at the air. The resident’s daughter reported a period without O2 while staff tried different concentrators and searched for equipment, estimating about 15 minutes before a portable O2 tank was brought back, at which point the NP pronounced the resident deceased. The DON later questioned why a portable O2 tank had not been used when the concentrators failed, and the NP stated the concentrator in use at the time of her assessment was not working properly.
Clogged Janitor Room Floor Drain and Black Water Overflow
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment for all 89 residents when a janitor room floor drain sink on one unit remained clogged and inoperable. During observation of the 400 Unit, water was seen coming from the janitor room into the hallway, and when the door was opened, the floor drain was observed to be filled with approximately 10 inches of black, dirty water. A housekeeper reported that she had spilled water in the hall while dumping her mop bucket into the floor drain sink and had mopped it up, and she confirmed that the drain was clogged and that this sink was used to dispose of cleaning chemicals from mop buckets. The housekeeper stated she had informed her supervisor about the clogged drain, but it had not been fixed and that it had been this way for “a while.” The housekeeping supervisor reported she had made several work orders regarding the janitor room and water overflow and that she and her staff had been unclogging the drain themselves for months. The maintenance director stated that housekeeping is responsible for their department and should notify him if anything is needed, that he had no active work orders regarding water overflow, and that housekeeping should have submitted a work order for the janitor room. He also stated that the black water could carry bacteria, mold, E. coli, salmonella, and possibly Legionella. The administrator stated he expects staff to place work orders and report issues immediately so they can be addressed right away.
Unlocked and Unattended Treatment Cart on Two Units
Penalty
Summary
The deficiency involves the facility’s failure to secure a treatment cart containing drugs and biologicals on the 500 and 600 units, affecting all 27 residents identified on those units by the census list provided by the Administrator on 04/29/26. On 04/29/26 at 8:40 a.m., surveyors observed at the nurses’ station that a treatment cart on the 500/600 unit was left unlocked and unattended, with no staff present. During an interview at 8:44 a.m., an LPN confirmed that the treatment cart was unlocked and identified it as the Treatment Nurse’s cart, noting that the Treatment Nurse was not on the unit at that time. On 04/30/26 at 2:06 p.m., the facility’s consultant nurse stated that treatment carts are supposed to be locked when not in use. The report states that this deficient practice could result in residents obtaining medication not prescribed to them, resulting in adverse side effects. No specific resident medical histories or conditions at the time of the deficiency are described in the report.
Failure to Honor Resident’s POA Request for Medical Records
Penalty
Summary
The facility failed to allow a resident’s designated representative, who held power of attorney (POA), to exercise the resident’s rights by obtaining the resident’s medical records. The resident had impaired cognitive function with a BIMS score of 5 and had formally designated a family member as POA effective 12/24/24, with authority over long‑term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. A nursing progress note documented that the POA approached the ADON and staff, stating she was still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the facility’s process for releasing records created a barrier for the POA, despite staff acknowledging her authority and the resident’s lack of capacity to request records independently. LPN #1 stated that family members requesting medical records had to go to Medical Records (MR). The MR staff confirmed that the POA requested the records and was given paperwork to complete on two occasions; the first form was filled out incorrectly, and the POA was told to redo it. MR reported that the corrected paperwork was not returned until after the resident died, at which point the facility required additional paperwork to release records after death. MR also acknowledged knowing that the POA could act on the resident’s behalf and that, unlike a resident’s oral request, the POA was required to complete written forms. As a result, the POA never obtained the resident’s medical records.
Failure to Provide Resident’s Legal Representative Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with access to the resident’s medical records upon request. The resident had impaired cognitive function, an impaired thought process, and a Brief Interview for Mental Status (BIMS) score of 5, and had designated a family member as Power of Attorney (POA) with authority over long-term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. Nursing progress notes documented that the POA approached the Assistant Director of Nursing and staff, stating they were still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the Medical Records (MR) staff required the POA to complete paperwork to obtain the resident’s medical records, even though MR acknowledged that the POA was legally authorized to act on the resident’s behalf and that the resident did not have the capacity to request records independently. MR reported giving the POA the required forms twice, stating the first set was filled out incorrectly and that the POA needed to complete them again. MR further stated that the POA did not return the corrected paperwork until after the resident’s death, at which point the facility required additional paperwork to release records following a resident’s passing. MR also stated that if a resident personally requested their own medical records, an oral request would be sufficient and no paperwork would be required. Despite the POA’s requests and authority, the POA never received the resident’s medical records. The facility’s policy on determining validity of authorization for release of protected health information required the Medical Records Director to determine whether an authorization was needed for disclosure, but the records were not provided to the POA prior to the resident’s death.
Failure to Update Care Plan With Family’s Restriction on Specific Staff Contact
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect a family member’s request regarding staff contact. Record review showed that the resident’s care plan, last revised on 06/26/25, did not include the family member’s request that a specific housekeeper not have contact with or provide care to the resident in the secure unit. The family member reported that this housekeeper had caused the resident to fall in her room, that the housekeeper was not a CNA in the secure unit, and that the previous Administrator and DON had informed the family member that the housekeeper would no longer work in the secure unit. The family member also stated that this information had been communicated to the current Administrator and DON when they started working at the facility. Interviews with facility staff confirmed that the housekeeper no longer worked in the secure unit and was not to have contact with or provide care to the resident, but this change was not documented in the resident’s care plan. The housekeeping supervisor stated that the housekeeper did not work in the secure unit due to the family member’s wishes. The housekeeper confirmed she no longer worked in the secure unit and was not to be in contact with or care for the resident. The MDS nurse, who is responsible for entering information into residents’ care plans, stated that staff had not informed her of the family member’s request and acknowledged that any changes to a resident’s care should be entered into the care plan. The ADON also confirmed that there was nothing in the care plan reflecting the family member’s wishes and stated that it should have been included.
Failure to Properly Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post the required Ombudsman contact information in areas accessible to residents and their representatives, as required by regulations mandating that names, addresses, and telephone numbers of pertinent State agencies and advocacy groups be posted along with a statement that residents may file a complaint with the State Survey Agency. On 04/29/26 at 9:35 AM, an observation of the facility revealed that staff did not have the Ombudsman information posted. Later that morning at 10:00 AM, an observation of the Activities Room showed that staff had placed an 8.5 x 11-inch paper with Ombudsman information roughly at eye level on the side of a refrigerator, rather than in a more generally visible or designated posting area. On 04/30/26 at 12:47 PM, the Administrator stated in an interview that the facility had taken down the Ombudsman posters in order to paint and confirmed that staff failed to put the Ombudsman posters back up after the painting was completed. This deficiency had the potential to affect all 89 residents identified on the census list provided by the Administrator on 04/29/26, as residents and their representatives would not be aware of how to contact the Ombudsman about concerns they have.
Failure to Maintain 18 Months of Posted Nurse Staffing Records
Penalty
Summary
The facility failed to retain 18 months of records for the daily posted nurse staffing information, affecting all 89 residents as identified on the census list provided by the Administrator on 04/29/26. During an observation of the front lobby at 8:54 AM on 04/29/26, surveyors noted that the current day’s nursing staff information was posted. However, in a subsequent interview at 8:58 AM, the DON, who reported being new to the position, stated she was unsure whether the facility maintained 18 months of the posted nursing staff information. In a later interview on 04/30/26 at 12:47 PM, the Administrator stated that the facility was attempting to obtain access to the historical posted nursing staff information but had been unable to do so. Because the facility did not have 18 months of posted staffing records available, residents or the public would not have access to review the required historical nurse staffing information.
Failure to Provide Adequate Evening and Nighttime Snacks to Residents
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences for evening and nighttime snacks. One resident reported that snacks were not offered very often, especially at night, and that when he asked for a snack he was sometimes told there were none available. Observation of the locked unit nourishment refrigerator showed only one labeled sandwich dated the previous day, along with unlabeled and undated yogurts, sandwich items in a white shopping bag, and two undated and unlabeled metal tumblers. RN staff stated that the snacks in the white shopping bag were intended for all residents who wanted a snack. Multiple CNAs reported that there were not enough snacks at night, noting that the kitchen was locked, and that only a small number of milk cartons, yogurts, supplement shakes, and a few sandwiches were available despite there being about 22 residents per hall. The Dietary Manager stated that snacks were put out three times a day only according to Registered Dietician orders, and that not everyone received a snack; snacks were not left in the refrigerator for residents, and staff could not access the kitchen at night. The DON reported that the kitchen previously put out a lot of snacks but stopped due to waste and cost, and that snacks were now limited to those prescribed by the Registered Dietician. Staff interviews, including CNAs and the Activities Assistant, indicated that residents without prescribed or labeled snacks frequently asked for snacks and were sometimes told there were not enough, leading staff to purchase snacks themselves or use vending machines to meet residents’ requests. These observations and interviews show that residents who wanted or needed snacks, including those with diabetes, did not have consistent access to adequate evening and nighttime snacks.
Unauthorized Discontinuation of Glaucoma Eye Drops
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when an ordered glaucoma eye drop medication for one resident was discontinued without a physician’s authorization. The resident was admitted with diagnoses including cerebral infarction, dementia, and glaucoma. Physician orders showed multiple start dates for Dorzolamide HCI-Timolol Maleate eye drops for both eyes, to be administered in the morning, evening, and at 5:00 a.m., with discontinuation dates entered in the record. Review of the medication administration record for March revealed that the resident did not receive the ordered eye drops because an active order was no longer available. Further review of nursing progress notes documented that the Dorzolamide HCI-Timolol Maleate eye drops had been discontinued by the facility on a specific date without a physician’s order to do so. During interviews, the administrator acknowledged that the eye drops were discontinued by accident and confirmed there was no physician authorization for discontinuation. An LPN reported that she accidentally discontinued the eye drops and did not realize the error for five days, at which point she recognized that the medication had been stopped in error. The DON also stated that the eye drop medication should not have been discontinued by accident because there was no physician order to discontinue it.
Failure to Provide Continuous Oxygen per Physician Orders Due to Equipment Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide continuous oxygen (O2) as ordered for a resident with significant pulmonary conditions. The resident had diagnoses including fracture of the left femur, COPD, acute respiratory failure, and pulmonary fibrosis, and had recently been hospitalized for a UTI and sepsis. Hospital records indicated diagnoses of pulmonary fibrosis, sepsis, and UTI, with a recommendation for palliative care. Upon discharge back to the facility, the physician’s order specified O2 at 2 liters per minute continuously via nasal cannula. Nursing progress notes documented that the resident arrived at the facility on a stretcher wearing 2 liters of O2, was restless and grabbing at the air, and was placed in bed while staff attempted to transition her from the ambulance’s portable O2 to the facility’s O2 concentrator. According to the nursing notes and interviews, the first O2 concentrator was ineffective, and the resident was temporarily placed on a portable O2 tank with a mask. The facility nurse then attempted to use various connectors and obtained another O2 concentrator, which also did not work properly. The resident’s daughter reported that once staff removed the ambulance’s portable O2 and attempted to use the facility concentrator, there was a period during which the resident was not on O2 while staff searched for another concentrator, and that it took approximately 15 minutes for the nurse to return with a portable O2 tank, by which time the nurse practitioner (NP) stated the resident had died and did not need O2. The DON later stated he questioned why a portable O2 tank had not been used when the concentrators were not working to maintain continuous O2 per the physician’s order. The NP confirmed that when she arrived, the resident was on O2 from a facility concentrator that was not working properly and that she did not know how long it had been malfunctioning before the resident’s death.
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