Luna Wellness Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Deming, New Mexico.
- Location
- 900 West Ash Street, Deming, New Mexico 88030
- CMS Provider Number
- 325079
- Inspections on file
- 21
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Luna Wellness Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that admission MDS assessments were not completed within the required 14-day timeframe for two residents. Record review showed that each resident’s admission MDS was finalized several weeks after admission, and an interview with the MDS Coordinator confirmed that staff did not complete these admission assessments on time.
Surveyors found that baseline care plans, which contain essential healthcare information needed upon admission, were not completed and finalized within 48 hours for two residents. Record reviews showed that each resident’s baseline care plan was dated shortly after admission but was not signed and locked until several days later, exceeding the required timeframe. In an interview, the MDS coordinator acknowledged that these baseline care plans were not completed within 48 hours and confirmed that the facility’s expectation is for baseline care plans to be completed within the first 48 hours of admission.
A resident with a documented coccyx pressure ulcer did not receive required Braden Scale pressure injury risk assessments for over a year. Record review showed no Braden Scale had been completed since early in the prior year, despite facility policy requiring these assessments on admission/readmission, weekly for four weeks, and then quarterly or with any change in condition. During interview, the MDS coordinator confirmed that the assessment had not been done as required.
The facility failed to maintain adequate staffing levels, resulting in CNAs being responsible for large numbers of residents, including several requiring two-person assistance or Hoyer lift transfers, and reporting that they must rush through showers and ADL care while call lights remain unanswered for extended periods. The scheduler and administrator acknowledged staffing challenges, high turnover, and an inability to consistently schedule the desired number of CNAs per shift, including limited coverage on night shift. A resident who requires setup assistance with eating, dressing, and toilet hygiene reported having to wait for help because staff are busy. Another resident, who needs substantial assistance with transfers, was observed with an unanswered call light and ultimately transferred himself to his wheelchair after waiting, while his nurse and CNA were occupied with wound care and no other staff were present on the unit; the resident and his sister reported frequent waits of 30 minutes or more for assistance and difficulty locating staff.
An unlocked medication cart on North Hall was observed in the hall with no staff present and medications stored in the unlocked drawers. The ADON confirmed the cart contained resident medications and that staff were expected to keep it locked when unattended.
Incomplete wound care and medication documentation: Staff failed to document wound care for one resident with a coccyx pressure ulcer and wound vac, failed to document zinc barrier cream administration for another resident, and failed to document wound care and repositioning for a third resident. The ADON and DON confirmed the missing MAR/TAR entries, and staff stated documentation should be completed when care is provided.
A resident’s MDS was inaccurate for a pressure wound review. The resident had a right heel deep tissue injury that later healed, but the Quarterly MDS still documented a pressure ulcer even though the wound was no longer present when the assessment was completed. The MDS coordinator confirmed the wound had healed and that it should not have been recorded as present.
Colostomy Care Not Ordered or Documented: A resident with a colostomy did not have colostomy care orders entered at admission, and staff did not document colostomy care before the orders were finally entered. Nursing notes showed the colostomy bag was changed, but the ADON and DON confirmed there was no documentation of care before the order date and they could not determine whether care was provided during the gap.
A resident with multiple chronic conditions and a history of falls was not accurately represented in the MDS assessment, as the assessment failed to document a fall with injury and the use of side rails for bed mobility, despite physician orders and care plan documentation.
Two residents with a history of falls had new interventions, such as fall mats and increased supervision, implemented by staff, but these changes were not documented in their care plans. Staff and leadership confirmed that care plans were not updated to reflect the most current fall prevention measures, despite facility expectations to do so.
The facility did not complete or document required safety assessments for bed rail use for two residents, including after a significant change in condition for one resident and prior to bed rail placement for another. Staff interviews revealed that bed rail consents were routinely obtained on admission, but safety assessments were not consistently performed or documented, and interdisciplinary team members confirmed these lapses.
A resident with a history of sexually inappropriate behavior was inadequately monitored, leading to multiple incidents of touching other residents without consent and making inappropriate comments. Despite having a care plan addressing these behaviors, interventions were removed prematurely, and staff failed to document or implement strategies to prevent further incidents. Several residents reported feeling unsafe, and staff were not adequately informed or instructed to monitor the resident's behavior.
The facility failed to report several allegations of abuse or neglect to the State Agency within the required timeframe. Incidents included inappropriate touching and comments by a resident, which were either not reported or delayed due to the administration's perception that they did not constitute abuse.
A facility failed to thoroughly investigate and implement preventive measures following multiple allegations of abuse involving a male resident. The incidents included inappropriate touching and comments towards female residents. The facility's documentation was inconsistent, lacking comprehensive witness statements and video evidence review. Staff were not consistently instructed to monitor the resident, and there was insufficient communication and documentation regarding actions taken to ensure resident safety.
The facility failed to update care plans for two residents, leading to deficiencies in addressing inappropriate behaviors and medical needs. One resident exhibited inappropriate behaviors, such as touching others without consent, which were not reflected in the care plan. Another resident's care plan lacked documentation of a fluid restriction order crucial for managing renal failure. Staff interviews revealed a lack of awareness and documentation regarding necessary monitoring and interventions.
A resident who alleged sexual abuse by a CNA did not receive timely mental health services, causing severe psycho-social distress. The facility delayed scheduling these services until the Ombudsman intervened, despite the resident's visible distress and emotional state.
A resident was sexually abused by a CNA while being assisted in the shower, causing severe emotional distress. The facility did not schedule behavioral health services for the resident until the Ombudsman intervened, despite the resident's visible distress and past trauma.
A facility failed to thoroughly investigate an abuse allegation and implement preventive measures after a resident reported that a CNA put his fingers inside her while assisting her in the shower. The investigation lacked detailed documentation and specific questioning of the CNA, and preventive actions were not promptly taken to ensure the resident's safety.
The facility failed to develop a comprehensive care plan for a resident, omitting essential details such as diagnosis, treatment/medications, and required assistance. The DON confirmed the care plan was incomplete and should have included the resident's specific needs.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Minimum Data Set (MDS) admission assessments within 14 calendar days of admission for two residents. Record review showed that one resident was admitted on an unspecified date, but the admission MDS assessment for this resident was not completed until 02/04/26. Another resident was also admitted on an unspecified date, and the admission MDS assessment for this resident was not completed until 01/28/26. During an interview on 03/12/26 at 1:55 PM, the MDS Coordinator confirmed that staff did not complete the admission MDS assessments for these two residents within the required 14-day timeframe. The report states that this deficient practice could likely result in residents’ needs not being met, and it was identified through record review of admission records and MDS assessments, as well as staff interview. No additional medical history or clinical condition details for the residents are provided in the report.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to create accurate baseline care plans within 48 hours of admission for two of three residents reviewed. Record review showed that one resident was admitted on an unspecified date, but the baseline care plan, dated 01/18/26, was not signed and locked (finalized by all authors) until 01/21/26, which exceeded the 48-hour requirement. Another resident was also admitted on an unspecified date, and their baseline care plan, dated 02/26/26, was not signed and locked until 03/02/26. During an interview on 03/12/26 at 1:50 PM, the MDS coordinator confirmed that the baseline care plans for these two residents were not completed within 48 hours of admission and stated that the expectation was for baseline care plans to be completed within the first 48 hours of admission. This failure to timely finalize baseline care plans, which contain the minimum healthcare information necessary to properly care for residents upon admission, was identified by surveyors as a deficient practice that could likely result in residents not receiving appropriate care and may place them at risk of an adverse event or worsening of their condition after admission.
Failure to Complete Required Braden Scale Assessments for Resident With Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in pressure injury risk assessment when record review showed that a resident with a documented coccyx pressure ulcer on 03/06/26 had not received a Braden Scale assessment since 01/07/25. Review of the resident’s assessments confirmed the absence of any Braden Scale evaluations after that date, despite the presence of a pressure ulcer. In an interview on 03/12/26 at 4:39 PM, the MDS coordinator acknowledged that no Braden Scale had been completed since 01/07/25 and confirmed that such assessments were required quarterly or with any change in condition. Review of the facility’s Pressure Injury Prevention and Management Policy further showed that licensed nurses were required to conduct Braden Scale assessments on admission/readmission, weekly for four weeks, and then quarterly or whenever the resident’s condition changed, which had not been followed for this resident.
Insufficient Staffing Leading to Delayed Assistance With ADLs and Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on each shift to meet residents’ needs, resulting in delayed care and inadequate assistance with activities of daily living (ADLs). Multiple CNAs reported being assigned large caseloads, including several residents requiring two-person assistance or use of a Hoyer lift, and stated there were not enough CNAs scheduled. CNAs described having to wait for help from other units, rushing through showers and ADL care, and leaving call lights unanswered for up to 30 minutes while they were occupied with other residents. One CNA reported that showers are done on day shift because there are not enough staff on night shift to complete them. The scheduler confirmed that only two to five CNAs are scheduled per 12-hour shift depending on availability, that there is high staff turnover, and that she often cannot find staff to cover call-ins. The administrator acknowledged staffing is a challenge, that he would like more CNAs on the floor than he is able to schedule, and that night shift typically has only two CNAs. Resident-specific findings further demonstrated the impact of staffing shortages. One resident’s care plan showed a need for setup/clean-up assistance with eating and hydration, and setup assistance with upper and lower body dressing and toilet hygiene; this resident reported that sometimes there are not enough staff and that he has to wait for assistance because staff are busy. Another resident’s MDS documented substantial/maximal assistance needs for sit-to-stand and partial/moderate assistance for toilet transfer and sit-to-lying, with supervision or touching assistance needed for lying to sitting. During an observation, this resident’s call light was on while no staff were present on the unit; the CNA had gone to lunch and the LPN and assigned CNA were occupied with wound care. By the time the scheduler responded to the call light, the resident had already transferred himself to his wheelchair, stating he did it himself after waiting. The resident and his sister reported that he had needed help to get out of bed, became tired of waiting, and that he sometimes waits 30 minutes or more for assistance and that it can be hard to find staff.
Unsecured Medication Cart on North Hall
Penalty
Summary
Medications were left unsecured in an unlocked medication cart on North Hall for all 24 residents on the unit. During observation, the medication cart was found in the hall unlocked, with no staff present at the cart and medications stored in the unlocked drawers. During interview, the ADON confirmed that the cart contained resident medications, that no staff were present at the cart, and that the medication cart was unlocked, despite staff being expected to keep the cart locked when unattended.
Incomplete wound care and medication documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for 3 residents reviewed for pressure ulcers when staff did not document wound care for 2 residents and did not document medication administration for 1 resident. The deficiency was identified through record review and staff interviews, and the report states that inaccurate or missing records could affect the accuracy of resident information available to staff and adversely impact the care provided. For one resident, the record showed admission to the facility and orders for wound vacuum dressing changes on Monday, Wednesday, and Friday, along with physician orders for wound care to a coccyx pressure ulcer with wound vac settings at 125 mmHg continuously. Nursing progress notes documented wound characteristics and measurements, and the physician noted the wound vac was in place, but the nursing record and MAR did not document that wound care or wound vac application was performed on 02/13/26. During interview, the ADON and DON confirmed the wound care nurse took measurements and would have completed wound care that day, but the care was not documented, and staff were expected to document all wound care in the medical record. For a second resident, the physician ordered zinc barrier cream to the coccyx twice daily, but the MAR did not document multiple applications across April and May 2026. The ADON stated he was the nurse working with the resident on one of the missed mornings, said he did apply the cream, and confirmed he did not document it. For the third resident, physician orders included repositioning and wound care to the coccyx with saline cleansing, packing, and dressings on a daily PRN basis, but the TAR did not document wound care on multiple dates and did not document repositioning on one date. An LPN confirmed wound care documentation should be completed when care is provided, and the DON confirmed the missing documentation and stated staff were expected to document when they reposition and provide wound care.
Inaccurate MDS Documentation of Healed Pressure Wound
Penalty
Summary
The facility failed to ensure the MDS was accurate for one resident reviewed for pressure ulcers. The resident was admitted with an order to apply skin prep to the right heel daily for a deep tissue injury, and a nursing progress note later documented that the deep tissue injury healed on 03/10/26 while skin prep continued as a preventative measure. However, the resident’s Quarterly MDS Assessment dated 03/23/26 documented that the resident had a pressure ulcer. During interview, the MDS coordinator confirmed the wound had healed on 03/10/26, that the resident did not have a pressure wound when the Quarterly MDS was completed, and that staff should not have documented a pressure wound on that assessment.
Colostomy Care Orders Not Entered or Documented
Penalty
Summary
The facility failed to meet professional standards of practice for a resident with a colostomy when staff did not enter colostomy care orders upon admission and did not provide documented colostomy care before the orders were entered. Record review showed the resident was admitted on [DATE] and discharged on 02/23/26. Nursing progress notes documented that the resident had a colostomy on 02/12/26 and that the colostomy bag was changed on 02/17/26, but there was no documentation of colostomy care between 02/12/26 and 02/16/26. The physician’s orders were not entered until 02/17/26, five days after admission, and included colostomy care once a day every three days starting 02/18/26, along with colostomy care as needed. The Administration Record for February 2026 did not show colostomy care provided before 02/18/26. During a joint interview on 05/13/26, the ADON and DON confirmed that staff did not enter colostomy care orders prior to 02/17/26, did not document colostomy care prior to that date, and that the wound care nurse took pictures of the colostomy without the bag on 02/13/26 and would have completed colostomy care after taking the pictures. They were unable to determine whether staff provided colostomy care between 02/13/26 and 02/16/26, and stated staff were expected to obtain colostomy care orders at admission.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment did not accurately reflect the resident's history of falls and the use of side rails for bed mobility and transfers. The resident, who was admitted with multiple diagnoses including chronic peripheral insufficiency, type 2 diabetes with skin complications, unilateral osteoarthritis of the left knee, generalized muscle weakness, need for assistance with personal care, and unspecified dementia with agitation, experienced several falls as documented in the facility's incident list. Despite these incidents and physician's orders for the use of 2 1/4 side rails to assist with mobility and independence, the MDS admission assessment failed to document a fall with injury and the use of side rails. The MDS coordinator confirmed during an interview that these details should have been included in the resident's assessment, indicating a lapse in accurately capturing the resident's needs and care requirements.
Failure to Revise Care Plans with Current Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect current interventions for two residents with a history of falls. For one resident admitted with repeated falls, the Interdisciplinary Team (IDT) added a fall mat as an intervention after a fall, and the mat was observed in use during a site visit. However, the resident's care plan was not updated to include this intervention. Similarly, another resident with multiple falls had several interventions in place, including the use of side rails, a fall mat, and placement in a common area for closer supervision, as confirmed by staff interviews and direct observation. Despite these interventions being implemented, the care plans for both residents did not document the use of the fall mat, call light within reach, or placement in a common area as fall prevention strategies. Staff interviews, including those with a CNA, LPN, MDS coordinator, and DON, confirmed that the care plans were not revised to include these interventions, even though facility expectations required such updates when new interventions were added.
Failure to Assess Bed Rail Safety and Obtain Consent
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the safety risks associated with bed rail use, specifically the risk of entrapment, for two out of three residents reviewed for accidents. For one resident, staff completed a bed rail assessment in January, but did not reassess after a significant change in condition in July, despite the resident experiencing several falls and a decline in mobility. Observations confirmed the presence of bed rails and a fall mat, and interviews with staff revealed that the resident was unaware of the risks of getting up unassisted and that bed rails were used as a fall prevention measure. However, no updated assessment was documented following the change in the resident's condition. For another resident, bed rails were in use as ordered by a physician to assist with mobility and independence, but there was no documentation of a side rail assessment in the medical record. Progress notes did not mention the use of side rails, and the care plan referenced their use without evidence of a prior safety assessment. Interviews with staff indicated that consents for bed rails were routinely obtained upon admission, but assessments for bed rail safety were not completed prior to their placement. The interdisciplinary team confirmed that residents should be assessed for bed rail safety before and after placement, especially following changes in condition, but acknowledged that these assessments and consents were not consistently documented or obtained.
Failure to Protect Residents from Inappropriate Behavior
Penalty
Summary
The facility failed to protect residents from abuse, specifically failing to prevent a resident with a history of sexually inappropriate behavior from engaging in such actions. This resident, who had diagnoses including vascular dementia and cerebral infarction, was not adequately monitored or managed, leading to multiple incidents where he touched other residents without consent, entered their personal spaces unclothed, and made inappropriate comments. Despite having a care plan that initially addressed these behaviors, the interventions were removed prematurely, and staff failed to document or implement strategies to prevent further incidents. Several residents reported feeling unsafe due to the actions of this resident. One resident, with a history of PTSD and hallucinations, reported being touched on the leg, which led to her feeling unsafe and experiencing hallucinations about the resident entering her room. Another resident, with moderate cognitive impairment, was subjected to inappropriate sexual comments, which she did not hear, but staff failed to take appropriate action to monitor the resident making these comments. Additionally, a resident with severe cognitive impairment was touched on the thigh, and although her power of attorney was informed, the facility did not take sufficient steps to prevent recurrence. The facility's staff, including CNAs and RNs, were not adequately informed or instructed to monitor the resident's behavior, leading to repeated incidents. Interviews with staff revealed a lack of awareness and documentation regarding the resident's inappropriate behaviors, and the facility's administration did not consider the incidents to be sexual in nature, despite evidence to the contrary. This lack of appropriate response and monitoring resulted in a failure to protect residents from potential harm and distress.
Removal Plan
- The current care plan was revised to observe/monitor behaviors of touching. Resident #24 was immediately placed on 15-minute observations. Then, every shift thereafter, when behavior resolves 15-minute safety check will resolve.
- Safety Surveys were conducted to ask all residents and nursing staff employees if they felt unsafe around Resident #24.
- Education has been provided to staff: To increase staff awareness of when an event occurs related to inappropriate sexual comments and/or behavior; the staff will communicate during daily huddles. Additional education provided include: Abuse and Neglect; 15-minute Safety Checks during a new event; then every shift for residents identified to have a pattern of inappropriate behaviors until resolved. Know your Resident - which includes the process for reviewing the pattern of current and past behaviors, and interventions in the Care Plan with all staff and new employees. Shift huddle handoff will include not only medical report but also behavior changes and or concerns.
- On-Going Monitoring: New events will require 15-minute checks for inappropriate behaviors. After 15 minutes checks have concluded, checks will be every shift for those residents that have a pattern of inappropriate behavior or show signs of behavioral escalation.
- CNA's making the 15-minute observation checks will immediately report to the charge nurse any changes in behavior or inappropriate sexual remarks or actions. For residents that have a history of behavioral issues, after the 15 minute checks have expired, the behavioral monitoring will occur every shift. Any changes and or escalation in behavioral will be reported.
- Attempts are made to provide education on care plan and current interventions to Resident #24. However, due to BIMS score of 3.0, the resident does not comprehend the education.
- The Charge nurse is to verify every shift with the CNA assigned of the 15-minute observations. Then every shift thereafter.
- All resident care plans have been updated to address observation and monitoring of the encouraging all residents on the reporting of any unwanted pilfering/physical contact, including verbalizations that maybe offensive from any other resident.
- If an event occurs going forward that involves inappropriate sexual comments and/or gestures, the resident will immediately be placed on 15-minute observation checks and the observation checks are documented for the established timeframe. The care plan will be updated to reflect the interventions put in place.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report multiple allegations of abuse or neglect to the State Agency within the required two-hour timeframe. This deficiency involved six residents who were either directly involved in or witnessed incidents of inappropriate behavior by another resident. For instance, a CNA witnessed a resident attempting to take another resident to his room while touching her thigh, but this incident was not reported promptly. Similarly, another resident reported feeling unsafe after being touched by a male resident, yet the facility delayed reporting this incident as well. The facility's administration did not consider some of these incidents as abuse, which contributed to the failure to report them. For example, an incident where a resident asked another if she liked sex was not reported because the administration believed the comment was not heard. Additionally, incidents where a resident entered another's room without pants and touched her leg, and another where a resident felt unsafe due to a male resident's actions, were not reported because the administration did not perceive them as abuse. These actions and inactions led to the deficiency in timely reporting of abuse or neglect allegations.
Inadequate Investigation and Prevention of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation and implement preventive measures following allegations of abuse involving multiple residents. The incidents involved a male resident, identified as R #24, who was reported to have inappropriate interactions with several female residents. These interactions included touching a resident's thigh, making inappropriate comments, and entering a resident's room without clothing. Despite these reports, the facility's documentation was inconsistent and lacked comprehensive witness statements, video evidence review, and clear preventive actions. In one instance, a resident's Power of Attorney was informed of an incident where another resident touched her thigh, but the facility handled the situation internally without clear communication of the actions taken. The facility's investigation reports were inconsistent, with discrepancies in incident dates and lack of detailed documentation regarding the review of video footage and witness statements. Additionally, the facility concluded that some incidents did not occur or were unsubstantiated without sufficient evidence to support these conclusions. The facility's response to these incidents was inadequate, as there were no specific interventions in place to address the behaviors of the resident involved in the allegations. Staff were not consistently instructed to monitor the resident, and there was a lack of clear communication and documentation regarding the actions taken to ensure the safety of the residents involved. This failure to properly investigate and implement preventive measures put residents at risk of continued abuse.
Care Plan Deficiencies for Resident Behaviors and Medical Needs
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in addressing inappropriate behaviors and medical needs. Resident #24 exhibited behaviors such as touching other residents without consent and entering their rooms, which were not updated in the care plan. Despite multiple incidents reported by staff and residents, including inappropriate touching and entering rooms without consent, the care plan lacked interventions to address these behaviors. Staff were not consistently instructed to monitor Resident #24 for these behaviors, and the care plan did not reflect the need for such monitoring. Resident #31's care plan was also deficient as it did not include a physician's order for fluid restriction, which was crucial for managing their renal failure. The care plan documented the need for monitoring fluid intake and output due to hemodialysis but omitted the specific fluid restriction order. This oversight could lead to inadequate management of the resident's condition, as the care plan did not provide complete guidance for staff on fluid management. Interviews with staff, including LPNs, CNAs, and the DON, revealed a lack of awareness and documentation regarding the necessary monitoring and interventions for these residents. The facility's interim DON acknowledged the staffing limitations that affected the ability to provide one-to-one monitoring for Resident #24. The absence of documented interventions and monitoring instructions in the care plans contributed to the deficiencies identified during the survey.
Failure to Provide Mental Health Services After Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide necessary mental health services for a resident who alleged sexual abuse by a staff member. The resident, who was admitted for therapy due to a right hip fracture, reported that a CNA sexually abused her during a shower. The incident was reported to the facility management, and the administrator initiated an investigation and reported it to the appropriate agencies. However, the facility did not schedule or consider behavioral health services for the resident until the Ombudsman brought it up during a meeting on a later date. The resident expressed severe psycho-social distress and depression due to the incident and her past trauma from an abusive relationship. Despite the resident's visible distress and emotional state, the facility delayed scheduling mental health services, which were only arranged after the Ombudsman's intervention. The facility's policy on abuse prevention includes follow-up counseling for residents in need, but this was not initiated promptly for the resident in question.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in severe psycho-social distress. The resident, who was admitted for therapy due to a right hip fracture, alleged that a CNA sexually abused her while assisting her in the shower. The incident was reported to the facility management, and the Administrator initiated an investigation and reported it to the appropriate agencies. However, the facility did not schedule or consider behavioral health services for the resident until the Ombudsman brought it up, despite the resident's visible distress and emotional trauma from the incident and her past abusive relationship. The resident expressed that the incident brought up past trauma and caused significant emotional distress. She reported the abuse to the facility management a week after it occurred, stating she was in shock and did not know what to say. The facility held a care conference with the resident and scheduled a mental health appointment, but this was only done after the Ombudsman intervened. The resident was visibly distressed during interviews and observations, crying and showing signs of emotional trauma when discussing the incident and her past abusive relationship.
Failure to Investigate Allegation of Abuse and Implement Preventive Measures
Penalty
Summary
The facility failed to conduct a thorough investigation and implement preventive measures following an allegation of abuse by a resident. The resident, who was admitted for therapy due to a right hip fracture, alleged that a CNA put his fingers inside her while assisting her in the shower. The incident was reported to have occurred one or two weeks prior to the report date. The facility's investigation did not include specific questions to the CNA about the incident, nor did it document any preventive or corrective actions taken to ensure the resident's safety. The facility's complaint investigation file lacked detailed documentation of the events surrounding the alleged abuse. Witness statements from staff members only referred to the moments when the resident reported the allegation, without any information about the time of the alleged incident. Additionally, the facility did not document any other witness statements or specific questions about the care provided by the CNA in question. The resident safe surveys conducted did not include questions related to sexual abuse or the CNA's bathing technique. During interviews, the resident expressed difficulty in reporting the incident due to past experiences of abuse and depression. The facility's administrator confirmed that the CNA was placed on administrative leave but was not specifically questioned about the resident's allegation. The facility's policy on abuse reporting and prevention was not fully adhered to, as the investigation did not gather comprehensive information from all relevant parties, and preventive measures were not promptly implemented to protect the resident from further harm.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for one of the two residents sampled for abuse. The resident was admitted on an unspecified date, and the admission Minimum Data Set (MDS) was completed on 02/05/24. However, the care plan dated 02/01/24 only included the resident's wish to return home, preferences for activities, and advanced directives for emergencies. It did not include essential details such as diagnosis, treatment/medications, and the assistance needed and provided by the facility. During an interview on 03/07/24, the Director of Nursing (DON) confirmed that the care plan was incomplete and acknowledged that it should have included the resident's specific needs of care.
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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