Laguna Rainbow Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Casa Blanca, New Mexico.
- Location
- 240 Casa Blanca Road, Casa Blanca, New Mexico 87007
- CMS Provider Number
- 325214
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Laguna Rainbow Nursing Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary food and beverage practices, including an RN serving drinks to residents while gripping cups by the rim with bare hands and reporting no specific training on dining service, despite facility expectations that cups be held by the side to prevent cross contamination. A kitchen tour further revealed expired canned corn, a cracked container of frozen strawberries left open to air, an expired and unsealable gallon of milk, and large amounts of spilled dressing and barbecue sauce on the sides of bulk condiment containers in the refrigerator, contrary to the Dietary Manager’s stated expectations for weekly date checks, proper storage, and prompt cleanup of spills.
Surveyors found that PASARR Level 1 screenings were inaccurately completed for four residents with documented depression. In each case, the PASARR indicated no mental illness, while the face sheet and MDS showed a diagnosis of depression and, for several residents, ongoing antidepressant therapy. During interview, the ADM confirmed the depression diagnoses and acknowledged they were not included on the PASARR forms, which should have been updated to reflect these mental health conditions.
Surveyors identified that a medication cart at the nurse’s station was left unlocked and unattended, contrary to facility expectations that carts remain locked when not in use, as confirmed by an RN and the DON. In addition, review of medication room refrigerator logs and direct observation showed temperatures repeatedly above the acceptable 36–46°F range, including readings of 48–65°F on several logged days and 50°F on the day of observation. A CMA and the DON both acknowledged the required temperature parameters and confirmed that the documented and observed temperatures were too high, creating a risk that medications stored there could become ineffective and unusable.
Surveyors found that two residents lacked any documented COVID-19 vaccine education, offering, or consent/declination forms in their medical records. Facility COVID-19 consent and education logs showed no completed forms for these residents, indicating they were not documented as having been offered vaccination. The IP reported that the residents’ POAs were unavailable when vaccines were administered and that one resident verbally declined the vaccine but never signed a declination form. The DON stated that all residents are expected to receive education and an offer of vaccination, with consents scanned into the chart and multiple attempts made to reach POAs, but confirmed this documentation was missing for both residents.
A resident with mental health diagnoses, including anxiety disorder and PTSD, was receiving Gabapentin three times daily for anxiety/seizure disorder without a completed and signed psychotropic medication consent form, as required by facility policy. Review of records showed no consent form for Gabapentin, and the DON confirmed that all psychotropic medications should have a consent form and acknowledged that the absence of this form affected the resident’s right to be informed about the medication and its potential side effects.
A resident with multiple medical conditions, including epilepsy, depression, HTN, and hypothyroidism, had a completed MOST form indicating DNR status, but staff did not update the comprehensive care plan to include this active code status. The care plan only referenced educating the resident and POA about health directives and having the physician complete a MOST form, despite the existing DNR order. The DON confirmed that advance directives are expected to be included in care plans and acknowledged that the resident’s code status was missing from the care plan.
The facility failed to ensure proper disposal of garbage and refuse when the outdoor trash bin was observed left open, with one side of the lid broken and unable to close. According to the Dietary Manager, the lid had been broken for several months, allowing the possibility for pests or rodents to access the trash and creating a hazard to staff and residents.
A resident with severe cognitive impairment was physically restrained by CNAs during toileting after becoming combative, resulting in a skin tear and bruising. Facility policy prohibits rough handling and requires staff to manage behaviors without causing injury or distress, but staff held the resident's hands across the chest to prevent striking, which was confirmed through interviews and documentation.
The facility did not provide adequate orientation or training for new and existing nursing staff, lacking formal policies and competency records. Leadership interviews confirmed that no onboarding process was in place until recently, and staff competency verification procedures were still being developed.
Several direct care staff, including a CNA and an RN, provided resident care without having received required training on abuse, neglect, and exploitation. Facility leadership and staff interviews revealed that there was no established onboarding or training verification process in place until recently, resulting in a lack of documentation and unclear responsibilities for ensuring staff competency.
A resident with dementia alleged being attacked by a male staff member, resulting in a thumb injury. The facility did not complete or document a timely and thorough investigation, and failed to provide confirmation that the required Five Day Follow-Up Report was promptly submitted to the State Agency. The report was ultimately received by the State Agency more than two months after the incident.
A resident with multiple chronic conditions died unexpectedly after offsite dialysis, and the facility did not report the death to the State Survey Agency, initiate an internal investigation, or document clinical findings in the medical record. Staff interviews confirmed that no incident report or mortality review was completed because the death occurred offsite.
A resident who died after being transported to dialysis was not properly documented in the facility's progress notes, and the discharge report inaccurately listed the resident as discharged to home instead of deceased. Facility leadership confirmed the documentation errors and stated that records should accurately reflect resident deaths.
Medications, including controlled substances stored in an E-Kit, were placed in a supply room accessible to all staff due to a keypad with a security flaw, allowing entry without a code. The supply room, used for personal care supplies, was accessible to CNAs and other non-licensed staff, contrary to facility policy that restricts access to controlled medications. Facility leadership and maintenance were unaware of the security vulnerability, resulting in medications not being properly secured.
Staff failed to maintain the dishwashing machine at the manufacturer's required minimum temperature of 120°F, with temperature logs showing repeated substandard readings. The facility's policy did not specify required temperatures, and staff continued to use the machine despite knowing it was not reaching proper levels, potentially affecting all residents due to improper dish sanitation.
A resident in a long-term care facility experienced sexual abuse by another resident, leading to significant psychosocial harm. Despite the facility's investigation and actions taken after the incident, the affected resident became withdrawn, experienced acute stress syndrome, and expressed a desire to leave the facility due to fear and lack of support.
The facility failed to ensure staff followed contact precautions for a resident with MRSA, as a housekeeper and CNA entered the room without protective gear. Additionally, the facility lacked a documented water management program to minimize Legionella risk, affecting all residents.
The facility did not designate a qualified Infection Preventionist (IP) to manage the infection prevention and control program (IPCP). After the resignation of the previous Director of Nursing, a nurse reported not being involved in infection control duties and lacking the necessary qualifications. The Interim Administrator confirmed that no official assignment of infection control responsibilities was made to the current staff.
The facility did not ensure CNAs received required dementia and abuse prevention training. A review showed 12 CNAs lacked this training. Interviews confirmed the training list was current and all staff should complete it. The Nurse Educator noted a training session occurred, but only attendees were documented, with no records for those absent.
A resident with impaired vision did not receive necessary vision services due to the facility's failure to schedule an appointment and arrange transportation. Despite the resident's request for assistance and a care plan goal to arrange annual consultations, an appointment was canceled without rescheduling following a facility evacuation due to a roof leak.
A resident with multiple health issues, including a pressure ulcer, did not receive necessary wound care for two days, leading to worsening conditions. The care plan required daily treatment, but the RN failed to perform the care as ordered, resulting in soiled bandages and increased drainage.
The facility failed to secure medications, as a nurse placed the medication room key in an unlockable drawer at the nursing station, which was sometimes unattended. Staff interviews revealed issues with key management, including CMAs being unavailable and keys being lost. The Interim Administrator and Pharmacist stated that keys should be kept on the person of nurses or CMAs to secure medications.
A facility failed to educate a resident's legal guardian on the benefits and potential side effects of the pneumococcal vaccine before obtaining consent. The legal guardian confirmed that no discussion occurred, and the nurse responsible for the oversight was no longer employed at the facility.
A resident with multiple diagnoses, including dementia and heart failure, experienced four falls in one month, three of which resulted in injury. The facility failed to update the resident's care plan until over a month later and did not complete updated fall assessments for two of the falls, leading to a deficiency in care planning.
A resident with dementia and Parkinson's disease was found with an injury of unknown origin to her right ankle. The LPN on duty failed to assess the injury immediately and did not notify the resident's POA or healthcare provider within the required two-hour timeframe. The injury was not assessed until two days later, resulting in a deficiency in the facility's notification procedures.
Unsanitary Beverage Service and Improper Food Storage and Handling
Penalty
Summary
The deficiency involves failure to store, prepare, and serve food and beverages under sanitary conditions. During a dining service observation, an RN was seen serving drinks to residents while gripping cups by the rim with bare hands on multiple occasions. In a subsequent interview, the RN reported having worked at the facility for six months and stated he had not received specific training related to dining service and distributing drinks to residents, although he acknowledged that cups should not be gripped from the top and should be handed to residents by holding the side. The Food Service Director later confirmed that her expectation is that staff assisting with dining service do not touch the rim of cups when serving, and that cups should be held by the side to avoid cross contamination and infection. A follow-up kitchen tour revealed multiple food storage and sanitation issues. Surveyors observed 21 cans of corn in dry storage with an expiration date of 12/28/2025, a cracked 6-lb container of frozen sliced strawberries left open to air in the freezer, and a 1-gallon container of whole milk past its expiration date that could not be sealed in the refrigerator. They also observed a 1-gallon container of Golden Italian dressing and a 1-gallon container of barbecue sauce with large amounts of spilled product on the sides of the containers in the refrigerator. In an interview, the Dietary Manager stated frozen foods should be discarded after one year in the freezer, staff are expected to check food expiration dates weekly, expired food must be discarded, and that the kitchen should not contain expired items, that food and beverages should be stored appropriately, and that spilled liquids should be cleaned.
Inaccurate PASARR Screenings for Residents With Depression
Penalty
Summary
The deficiency involves the facility’s failure to ensure Level 1 PASARR screenings were reviewed for accuracy and completion for four residents with documented mental health diagnoses. Record review showed that one resident was initially admitted with a diagnosis of depression, and this diagnosis was also documented on the resident’s MDS dated 01/15/26. However, the resident’s PASARR Level 1 Identification Screen dated 07/29/24 indicated “No” to having a diagnosis or suspected mental illness, and the depression diagnosis was not reflected on the PASARR. For a second resident, the face sheet showed admission with certain diagnoses, and the PASARR Level 1 dated 01/10/26 documented no diagnosis or suspected mental illness, while the MDS indicated a diagnosis of depression and use of an antidepressant. For a third resident, the PASARR Level 1 dated 02/05/26 documented no diagnosis or suspected mental illness, while the face sheet listed diagnoses at admission and the MDS showed a diagnosis of depression and receipt of an antidepressant. For a fourth resident, the PASARR Level 1 dated 08/26/25 also indicated no diagnosis or suspected mental illness, despite the face sheet listing admission diagnoses and the MDS documenting depression and antidepressant use. In an interview on 03/12/26, the Administrator confirmed that all four residents had diagnoses of depression and acknowledged that these mental health diagnoses were not reflected on their PASARRs, and that updated PASARRs should have included the depression diagnoses.
Unlocked Med Cart and Improper Medication Refrigerator Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to properly secure a medication cart and to maintain appropriate storage temperatures for medications. During an observation at the nurse’s station, one medication cart used for storage, transport, and administration of medications was found unlocked and unattended. In interviews, an RN stated that medication carts should always be locked when unattended and acknowledged that leaving them unlocked could allow residents and visitors access to medications. The DON similarly stated her expectation that medication carts be locked at all times when unattended and confirmed that if carts are left unlocked, anyone could access the medications. The facility also failed to maintain the medication storage room refrigerator within the required temperature range of 36 to 46 degrees Fahrenheit. Review of the refrigerator temperature logs for a two-month period showed recorded temperatures of 65°F on one date and 48°F on two other dates. During an observation of the medication room, both the built-in and portable thermometers in the medication refrigerator showed a temperature of 50°F. A CMA stated the refrigerator temperature should be around 42°F and not more than 46°F, and confirmed the observed 50°F reading. The DON stated that the medication refrigerator temperature should be within the appropriate range, documented daily, and confirmed that 50°F was too warm and that medications not stored at the correct temperature can become ineffective and unusable for residents.
Failure to Document COVID-19 Vaccine Education and Offering for Two Residents
Penalty
Summary
The facility failed to ensure that residents' medical records contained documentation of education, offering, or administration of the COVID-19 vaccination for two of five residents reviewed. Record review showed that one resident was admitted on a specified date, but there was no completed COVID-19 vaccination consent and education form in the facility’s COVID-19 consent and education documentation, indicating the resident was not offered the vaccine. Similarly, another resident admitted on a specified date also had no completed COVID-19 vaccination consent and education form in the documentation provided by the facility, likewise indicating that this resident was not offered the COVID-19 vaccine. During an interview, the Infection Preventionist stated that at the time COVID-19 vaccines were being administered, the powers of attorney for both residents were unavailable to provide consent. The Infection Preventionist reported that one of the residents verbally stated he did not want the vaccination and would have been able to sign a consent form declining the vaccine, but this was not done. The Infection Preventionist confirmed that neither resident had completed COVID-19 consent and education forms and that they should have. In a separate interview, the DON stated that her expectation is that every resident be educated and offered the COVID-19 vaccination, that consent forms are scanned into the chart, and that multiple attempts should be made to contact the POA; she confirmed that neither of the two residents had completed COVID-19 consent and education forms and that they should have.
Failure to Obtain Psychotropic Medication Consent for Gabapentin
Penalty
Summary
The facility failed to obtain a completed and signed psychotropic medication consent form prior to administering a psychotropic medication to a resident. The facility’s psychotropic medication use policy, last revised in July 2022, defined psychotropic medications as those affecting brain activity and included antipsychotics, antidepressants, antianxiety medications, and hypnotics. Record review showed that a resident was admitted with diagnoses including a manic episode, anxiety disorder, and PTSD. Physician orders dated 8/24/25 directed administration of Gabapentin 100 mg by mouth three times daily for anxiety/seizure disorder. Review of the resident’s psychotropic medication consent forms dated 03/12/26 revealed that no consent form for Gabapentin had been completed or was available. During an interview on 03/12/26 at 2:00 p.m., the DON stated that any medication listed as a psychotropic should have a consent form and acknowledged that the resident did not have a consent form completed for Gabapentin use, despite one being required. The DON further stated that the lack of a psychotropic consent form affected resident rights, as residents have the right to know what medications they are receiving and to be informed of potential side effects.
Failure to Update Care Plan With Resident’s DNR Code Status
Penalty
Summary
Facility staff failed to revise and update a resident’s comprehensive care plan to include the resident’s current advance directive code status. Record review showed the resident was admitted with diagnoses including generalized idiopathic epilepsy with status epilepticus, depression, hypertension, and hypothyroidism. A Medical Orders for Scope of Treatment (MOST) form dated 02/11/2026 documented the resident’s code status as Do Not Resuscitate (DNR). However, the resident’s current care plan, dated 02/13/2026, did not include the active code status. Instead of documenting the resident’s DNR status, the care plan only indicated that staff would educate the resident and the resident’s Power of Attorney regarding health directives and have the physician complete a MOST form, despite the MOST form already being completed and specifying DNR. During an interview on 03/10/2026 at 2:14 pm, the DON stated it was her expectation that residents’ advance directives be included in their care plans and confirmed that this resident’s care plan did not include the advance directive code status and that it should have.
Failure to Maintain Covered Outdoor Trash Bin
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not maintaining the outdoor trash bin in a covered condition. On 03/12/26 at 11:37 a.m., surveyors observed the outdoor trash bin left open, with only one side of the lid able to be closed and the other side broken. During an interview at 11:50 a.m. the same day, the Dietary Manager stated that the outdoor trash bin lid was broken and that they had been trying to fix the lid for the last six months. She also stated that pests or rodents can get into the trash and that it is a hazard to staff and residents. The report notes that if staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to residents.
Inappropriate Use of Physical Restraint During Resident Care
Penalty
Summary
Facility staff failed to protect a resident with severe cognitive impairment, including diagnoses of unspecified dementia and Alzheimer's disease, from inappropriate use of physical restraint during care. According to interviews and record reviews, two CNAs attempted to assist the resident with toileting when the resident became combative, swinging arms and attempting to strike staff. In response, one CNA held the resident's hands across the chest to prevent hitting, which is considered a form of physical restraint. The facility's policy prohibits rough handling and requires staff to manage behaviors in a way that prevents injury, pain, or distress. Documentation revealed that following the incident, the resident was found to have a skin tear on the right lower abdomen and a large bruise on the right hand. Staff interviews confirmed that the restraint was applied during care, and the Assistant Director of Nursing acknowledged that staff should have stepped away and notified nursing staff rather than continuing care during combative behavior. The Administrator confirmed that restraining residents during care is not acceptable per facility expectations and policy.
Lack of Staff Competency Due to Inadequate Orientation and Training
Penalty
Summary
The facility failed to ensure that nurse aides and nursing staff were competent to perform their assigned duties due to a lack of adequate orientation and training for both new and existing employees. Record review revealed that the facility did not have a formal policy or process in place for onboarding, orientation, or training of staff. Additionally, the facility was unable to provide training and competency records for several staff members, including certified nurse aides and a registered nurse. Interviews with facility leadership confirmed that there was no onboarding process for staff prior to July of the current year. The Assistant Director of Nursing (ADON) acknowledged oversight of CNA training but stated that no onboarding process existed before that time. The Human Resources Director, who had only recently joined the facility, also confirmed the absence of a formal onboarding process for nursing staff. The Staffing Coordinator and Director of Nursing further corroborated that there were no established policies or procedures for staff onboarding or competency verification, and that the process was still under development.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received training on abuse, neglect, and exploitation prior to providing direct resident care. Record review showed that there was no documentation of such training for several staff members, including Certified Nurse Aides and a Registered Nurse. Interviews with staff and leadership revealed that there was no onboarding process in place until recently, and responsibilities for verifying staff qualifications and training were unclear among the Assistant Director of Nursing, Staffing Coordinator, and Human Resources. The Director of Nursing confirmed that policies and procedures for onboarding and competency verification were not established when she began her employment, and the process was still under development at the time of the survey. Direct care staff, including a Registered Nurse and a Certified Nurse Aide, confirmed during interviews that they had not received abuse, neglect, and exploitation training, despite already providing resident care. The Administrator acknowledged awareness of the training and competency issues and stated that efforts were underway to organize records and implement a tracking process for staff trainings. There were no details provided about specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to complete and document a timely and thorough investigation regarding an allegation of abuse involving a resident with dementia and behavioral issues. The incident involved the resident alleging that she was attacked by a male staff member during the night shift, resulting in a thumb injury, but she was unable to provide specific details or identify the staff member. The facility's Five Day Follow-Up Report, which is required to be sent to the State Agency to document the results of the investigation, was undated and the facility could not provide confirmation that the report was received by the State Agency. State Agency records showed the report was not received until over two months after the incident, and the Director of Nursing was unable to provide evidence of timely submission.
Failure to Report Unexpected Resident Death and Initiate Investigation
Penalty
Summary
The facility failed to report an unexpected death of a resident to the State Survey Agency and did not initiate an internal investigation or document clinical findings in the medical record following the event. The resident, who had diagnoses including end-stage renal disease, chronic respiratory failure with hypoxia, diabetes mellitus, and hypertension, passed away after attending dialysis offsite. Despite the unexpected nature of the death, the facility did not complete an incident report or conduct a mortality investigation. Interviews with facility staff, including the ADON and Administrator, confirmed that no formal review or report was submitted to the State Survey Agency because the death occurred offsite. The Medical Director was notified of the death and stated an expectation that the facility would notify the State Survey Agency in such cases. Review of the resident's progress notes and records showed no evidence of an internal investigation or reporting of the event.
Failure to Accurately Document Resident Death and Discharge Status
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical record for a resident who died after being transported to dialysis. Staff did not document in the progress notes that the resident was transported to dialysis and subsequently died at the dialysis center. Additionally, the facility's Admit/Discharge Report inaccurately listed the resident as discharged to home or self-care, rather than deceased. During interviews, the Assistant Director of Nursing confirmed the resident's death after dialysis, and the Administrator acknowledged the discharge status was not updated to reflect the resident's death. The Medical Director stated that staff are expected to document resident deaths in the clinical record and ensure records accurately reflect the resident's status.
Medications and Controlled Substances Not Properly Secured
Penalty
Summary
The facility failed to ensure that medications, including controlled substances, were properly secured and inaccessible to unauthorized staff. According to the facility's own policy, only authorized licensed nursing and pharmacy personnel should have access to controlled medications, and the access system for these medications should be separate from that used for non-scheduled medications. However, observations revealed that the supply room, which contained over-the-counter medications and an emergency kit (E-Kit) with controlled substances such as morphine, Xanax, and Temazepam, could be accessed by all staff, including CNAs, due to a keypad with an exposed spring that allowed the door to be opened without entering a security code. The E-Kit and medications had been moved to the supply room following a pharmacist's recommendation due to temperature concerns in the medication room. Interviews confirmed that the supply room was accessible to all facility staff because it also contained personal care supplies needed for residents. The DON acknowledged that the E-Kit in the supply room posed a potential hazard since controlled medications were accessible to unauthorized staff. Maintenance staff were unaware of the security flaw with the keypad, and the Administrator confirmed that all staff had access to the room and was not aware that the security code could be bypassed. These actions and inactions resulted in medications not being properly secured as required by facility policy and regulatory standards.
Failure to Maintain Required Dishwashing Temperatures for Proper Sanitation
Penalty
Summary
The facility failed to properly sanitize dishes due to not maintaining the dishwashing machine at the required minimum temperature of 120°F, as specified by the manufacturer's instructions. The facility's dishwashing policy did not address the necessary water temperature for sanitizing dishes, and temperature logs for the dishwashing machine consistently showed wash temperatures below 120°F over a period of several days. Staff, including the Dietary Manager and kitchen staff, were aware that the dishwashing machine was not reaching the appropriate temperature, and the Registered Dietician noted that at least half of the recorded temperatures for the month were below the required level. The dishwashing machine was identified as a low-temperature, chemical sanitizing model, but both the manufacturer’s recommendations and the machine’s name plate indicated that a minimum temperature of 120°F was necessary for effective sanitation. Despite being aware of the issue, staff continued to use the dishwashing machine for cleaning dishes and cooking equipment, and the Administrator acknowledged not knowing the correct temperature for the wash and rinse cycles. The outside lab technician confirmed that the machine required a boost heater to reach the necessary temperature. The deficiency was likely to affect all 33 residents in the facility, as the improper sanitization of dishes could expose them to foodborne illnesses.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse, resulting in psychosocial harm and distress for a resident. The incident involved a male resident entering the room of a female resident, who was asleep, and engaging in non-consensual sexual activity. The female resident, who had a history of depressive disorder and chronic pain, reported the incident to the nursing staff the following day. The facility was notified, and an investigation was initiated, but the incident had already caused significant emotional distress to the resident. The resident experienced acute stress syndrome following the incident, as diagnosed by a psychiatrist. She became more withdrawn, isolated, and expressed fear and anxiety about staying in the facility. The resident's psychosocial assessment indicated that she was staying in her room more often and had nightmares related to the incident. Her weight also decreased significantly over the following months, indicating a decline in her overall well-being. The facility's response included notifying the resident's Power of Attorney and arranging for a Sexual Assault Nursing Exam (SANE) at the hospital. However, the resident continued to express a desire to leave the facility due to fear and lack of support. The facility's investigation report noted that the male resident was placed on one-to-one supervision and later discharged, but the female resident's condition continued to deteriorate, highlighting the facility's failure to protect her from abuse and provide adequate support after the incident.
Failure to Follow Contact Precautions and Lack of Water Management Program
Penalty
Summary
The facility failed to ensure that staff adhered to contact precautions for a resident who was admitted with methicillin-resistant Staphylococcus aureus (MRSA) in a coccyx wound. Observations revealed that a housekeeper and a certified nurse assistant (CNA) entered the resident's room without wearing gloves or an isolation gown, despite a contact precautions sign on the door instructing staff to do so. The housekeeper was unaware of the contact precautions, and the CNA believed protective gear was only necessary when cleaning the resident's wound. A nurse confirmed that both staff members were expected to follow the contact precautions. Additionally, the facility did not have a documented water management program to minimize the risk of Legionella and other pathogens in the building's water systems. Interviews with the maintenance technician and the facility's administrator revealed that there was no water testing system or related documentation in place. This lack of a water management program affected all residents in the facility, increasing the risk of exposure to Legionella bacteria.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the infection prevention and control program (IPCP). This deficiency was identified through interviews and record reviews. During an interview, a nurse stated that the previous Director of Nursing, who resigned at the end of November 2024, did not involve her in the infection control process, and she was not asked by the Interim Administrator to perform any infection control duties. Furthermore, she lacked the qualifications to carry out infection prevention and control tasks. The Interim Administrator confirmed that the previous Director of Nursing managed infection control reporting and that neither the interviewed nurse nor the current senior ranking nurse was officially assigned any infection control responsibilities.
Deficiency in CNA Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required training in dementia care and abuse prevention. A review of the facility's training records from December 2023 to December 2024 revealed that 12 out of 19 CNAs did not receive the necessary training. Interviews with the Social Services Director and the Interim Administrator confirmed that the training list was current and that all nursing staff were expected to complete the trainings. The Nurse Educator stated that a dementia training session was held on November 26, 2024, but only those who signed the attendance sheet participated, and there was no documentation for those who missed the session to show they had reviewed the training materials.
Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
The facility failed to assist a resident in gaining access to vision services, as evidenced by the lack of appointment scheduling and transportation arrangements for the resident. The resident, who had impaired vision as documented in both the Admission and Quarterly Minimum Data Sets, expressed that she had requested assistance from staff to schedule an eye appointment earlier in the year but did not receive a response. The resident's care plan, dated 10/4/24, included a goal to arrange for an Ophthalmologist or Optometrist consultation annually and as needed, which was not fulfilled. Nurse #4 confirmed that an eye appointment was initially scheduled for the resident on 6/14/24, but it was canceled due to a lack of transportation. Following the cancellation, the facility experienced a widespread roof leak that necessitated an evacuation, and the appointment was not rescheduled. This series of events led to the resident not receiving the necessary vision services, which could potentially impact her health and quality of life.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with pressure ulcers, leading to a worsening of the condition. The resident, who was initially admitted with multiple diagnoses including muscle wasting, type 2 diabetes with neuropathy, and stage 4 chronic kidney disease, was readmitted with a Stage 2 pressure ulcer on the coccyx. The care plan outlined that the resident's wounds should heal without complications and specified that staff should provide care according to the provider's orders, including sending the resident to the emergency room for evaluation and treatment as needed. However, the facility did not adhere to the physician's orders for wound care, which included daily cleansing and dressing of an unstageable pressure ulcer on the sacrum. The Wound Care Nurse reported that the resident's wound care was neglected for two consecutive days, resulting in grossly soiled bandages with significant blood and drainage. The Director of Nursing's follow-up report confirmed that the assigned RN failed to complete the required daily wound care on the specified dates, contributing to the deterioration of the resident's condition.
Medication Security Lapse in Facility
Penalty
Summary
The facility failed to ensure that medications were secured and inaccessible to unauthorized staff and residents. During an observation, a nurse was seen placing the medication room key inside an unlockable drawer at the nursing station. This practice was confirmed by the nurse, who stated that someone was always present at the nursing station to guard the drawer. However, an observation later revealed that the nursing station was unattended, leaving the key and potentially the medication room unsecured. Interviews with staff revealed further issues with key management. A nurse mentioned that Certified Medication Aids (CMAs) were responsible for holding the medication room key, but they were not always available when needed. Additionally, keys were often lost when staff took them home, prompting the decision to keep the key in the drawer. The facility's Interim Administrator and Pharmacist both expressed that the key should not be kept in an unlocked drawer and should be kept on the person of the nurses or CMAs to ensure the security of medications, including insulin and over-the-counter drugs.
Failure to Educate Legal Guardian on Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a nurse provided education to a resident's legal guardian about the benefits and potential side effects of the pneumococcal immunization before offering the immunization. This deficiency involved a resident whose legal guardian was her son. The physician's order to administer the Prevnar vaccine was dated 11/25/24, and the legal guardian had consented to the immunization. However, the progress notes from 11/19/24 indicated that Nurse #5 called the legal guardian to obtain consent but did not document any education on the benefits or potential side effects of the vaccine. During an interview, the legal guardian confirmed that the nurse did not discuss these aspects. Nurse #4 stated that she expected Nurse #5 to provide this education, but Nurse #5 was no longer employed at the facility.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after multiple falls, which is a deficiency in care planning. The resident, who was admitted with diagnoses including heart failure, anxiety disorder, restlessness, agitation, and unspecified dementia, experienced four falls in August 2024. These falls included one without injury and three with injuries. Despite the falls, the facility did not update the resident's care plan until late September 2024. Additionally, the facility did not complete updated fall assessments for two of the falls that occurred in August, further contributing to the deficiency in care planning.
Failure to Notify POA and Provider of Resident Injury
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) and healthcare provider of a resident when staff discovered an injury of unknown origin. The resident, who had dementia and Parkinson's disease, was found with an injury to her right ankle. Despite being informed of the injury, the Licensed Practical Nurse (LPN) on duty did not assess the injury immediately and instead passed the information to an incoming night nurse without ensuring the assessment was completed. The injury was not assessed until two days later when the LPN returned from days off. The Director of Nursing (DON) confirmed that the staff did not notify the resident's POA or the on-call provider about the injury within the required two-hour timeframe. The facility's policy mandates that such notifications be made promptly to allow the POA and provider to make informed decisions regarding the resident's care. The delay in notification and assessment resulted in a failure to comply with the facility's procedures for handling injuries of unknown origin.
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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