Northrise Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 2884 North Road Runner Parkway, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325111
- Inspections on file
- 22
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Northrise Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident’s POA informed the ADON at admission that the resident wished to be DNR and stated he had a DNR form in his car, but he did not return with the form. The ADON did not document the POA’s DNR request in the medical record and did not contact the provider to obtain a DNR order, leaving no DNR order on file. When the resident was later found unresponsive, staff called EMS, applied AED pads, and EMS initiated CPR and transported the resident to the hospital. An intake report noted that CPR was initiated against the POA’s DNR wishes, demonstrating a failure to honor the requested code status due to missing documentation and physician orders.
A resident was admitted with an unstageable pressure ulcer documented on the Admission MDS, along with a need for pressure ulcer/injury care, but the baseline care plan created within 48 hours did not include the pressure ulcer or the need for wound care. During interview, the DON confirmed the omission and stated the expectation that nurses care plan wounds and necessary wound care within the first 48 hours of admission.
Surveyors found that two residents with documented unstageable pressure ulcers and identified needs for pressure ulcer care on their admission MDS and Care Area Assessments did not have corresponding pressure ulcer or wound care interventions included in their comprehensive care plans. One resident’s care plan lacked any pressure ulcer component despite multiple unstageable and deep tissue injuries noted on admission, and another resident’s care plan omitted pressure ulcer care until it was added at a later date. The DON acknowledged that the comprehensive care plans for these residents did not address their pressure ulcers or wound care needs, contrary to facility expectations.
Surveyors found that wound care orders for two residents’ buttock wounds were not accurately documented on the Treatment Administration Record (TAR). One resident’s ordered daily wound care was missing documentation on multiple specific days, and another resident’s ordered wound care lacked documentation over an extended period. The Wound Care Nurse reported that she completed the ordered treatments on numerous dates but did not record them on the TAR, sometimes relying on the unit nurse to document instead. This resulted in incomplete and inaccurate medical records related to wound care.
A staff member was employed as an LPN using false credentials and provided care to residents without a valid license. During her employment, she demonstrated significant skill deficiencies, including improper Foley catheter handling, medication errors, incomplete documentation, and required frequent supervision and assistance from other staff. These issues were reported by multiple staff members and confirmed through disciplinary records and interviews.
A resident was subjected to improper medication administration and incomplete care by a staff member who was later found to be working under false credentials. Staff observed and reported concerns about this individual's actions, including leaving medications at the bedside and attempting incorrect IV procedures, but the facility did not report these allegations of neglect to the State Agency as required.
The facility failed to implement a water management program to minimize the risk of Legionella and other pathogens, potentially affecting all 27 residents. Key staff, including the Director of Maintenance and the DON, were unaware of their roles in preventing pathogen growth, contributing to the deficiency.
The facility failed to designate a qualified Infection Preventionist (IP) for its Infection Prevention and Control Program (IPCP). The DON is currently performing IP duties due to the IP's leave related to nursing license issues. This deficiency could affect all 27 residents in the facility.
The facility failed to develop comprehensive care plans for three residents, omitting critical information such as severe vision impairment, activity preferences, and required assistance for ADLs. This lack of documentation could lead to staff being unaware of the residents' needs.
The facility failed to ensure proper IDT participation in care plan meetings and did not update a resident's care plan to reflect a new pressure ulcer. Meetings often lacked key team members, and a resident's care plan was not revised to include a newly developed stage I pressure ulcer, potentially affecting care quality.
The facility failed to secure treatment carts on the East Unit, leaving them unlocked and unsupervised. An IV treatment cart containing sterile needles and catheters was found open, confirmed by an RN to be against protocol. Another cart with medications and scissors was also left unlocked, as confirmed by an LPN.
A fish oil supplement, 1000 mg, was found expired in the medication cart on the East Unit, intended for residents with rheumatoid arthritis. RN #16 confirmed the expiration, and the DON stated that expired medications should not be present and should be checked each shift.
The facility failed to ensure that call light pull cords in resident rooms were accessible, with cords being too short to reach unless residents were in bed. One resident's wife noted her husband was not cognizant enough to use the cord, while another resident had a trash bag tied to the cord to extend its reach. The Maintenance Director confirmed the cords were shortened to prevent tangling, leaving no alternative for residents unable to pull the cord.
The facility failed to provide written notifications to residents and their representatives regarding transfers and discharges, affecting five residents. One resident's POA only received a verbal notice and had to independently seek appeal information. The facility did not issue written transfer notices for hospitalizations due to various medical conditions. Staff confirmed that notifications were made via phone, and the Ombudsman was not informed of discharges or transfers.
The facility failed to provide written bed hold notices to residents or their representatives when transferred to the hospital. This deficiency affected four residents who were hospitalized for various medical conditions, including altered mental status and gastrointestinal bleeding. The Director of Nursing confirmed that staff did not complete the required notices, potentially leaving residents unaware of the bed hold policy.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in documenting conditions such as pressure ulcers, falls, and MASD. Interviews confirmed these inaccuracies, which could result in inadequate care planning.
The facility failed to document accurate baseline care plans within 48 hours for three residents, leading to potential risks of inadequate care. One resident's wounds and necessary interventions were omitted, another's MASD diagnosis was not documented, and a third resident's dysphagia, PEG tube, and diet orders were not included. The MDS Coordinator confirmed these omissions.
A facility failed to obtain and implement wound care orders for a resident with a Stage II pressure ulcer on the coccyx. Despite the ulcer being present upon admission, there were no wound care orders in place until several days later. Nursing staff did not consult with the facility provider to obtain necessary orders, and the Director of Nursing acknowledged the oversight, which could lead to inconsistent interventions and worsening of the ulcer.
A facility failed to ensure a resident with a condom catheter had a physician's order and a documented clinical condition justifying its use. The resident, who was continent, had a catheter without an order or clinical documentation. The DON confirmed the absence of necessary documentation, contrary to facility expectations.
A facility failed to change a resident's nasal cannula within the required 7-day period, as observed during a survey. The resident's cannula lacked a date indicating when it was last changed, despite a physician's order for continuous oxygen. The DON stated that cannulas are changed weekly, but a CNA could not confirm if the resident's cannula had been changed, potentially affecting the resident's oxygen supply.
A resident was inappropriately administered Remeron, an antidepressant, for muscle weakness, which is not a valid medical diagnosis for its use. The resident's diagnoses included cognitive communication deficit and severe dementia without behavioral disturbances, none of which justified the medication. The DON confirmed the inappropriate prescription, highlighting a failure to ensure medications were medically necessary.
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in wound care and skin condition management. One resident did not receive documented wound care for several days after admission, and another resident developed MASD without provider notification or treatment documentation. Staff interviews confirmed lapses in assessing and documenting care, highlighting a failure in the facility's processes for managing residents' conditions.
The facility failed to report investigation results of alleged medication diversion and injuries of unknown origin to the State Agency within five days. A resident with unexplained fractures and missing narcotics from the Emergency Kit were not properly documented or reported, as confirmed by the DON.
The facility did not post daily nurse staffing data, omitting the total number and actual hours worked by RNs, LPNs, and CNAs. An observation revealed missing information at the entrance, and the DON confirmed the night shift nurse's responsibility for posting complete data.
The facility failed to develop care plans addressing the individualized discharge goals and needs for three residents reviewed for discharge planning. Record reviews and an interview with Social Services staff confirmed the absence of such documentation in the residents' care plans and charts.
Failure to Honor POA-Requested DNR Due to Lack of Documentation and Orders
Penalty
Summary
The deficiency involves the facility’s failure to have a functional system to ensure staff could correctly initiate or withhold CPR in accordance with a resident’s code status and the POA’s expressed wishes. During admission, the ADON documented that the resident had a POA and that the POA stated the resident wished to be DNR, and the POA reported having a DNR form in his car but did not return with it. The ADON did not document the POA’s DNR request in the medical record and did not contact the provider to obtain a DNR order, resulting in the absence of any DNR order in the physician’s orders or medical record. The DON later confirmed that the admitting nurse should have contacted the physician and that staff should have entered the DNR status in the medical record. Subsequently, staff went to check on the resident and found her unresponsive. EMS was called, AED pads were applied with no shock advised, and EMS initiated CPR and transported the resident to the hospital. An intake report documented that CPR was initiated against the POA’s DNR wishes. Because the resident’s DNR request, as communicated by the POA, was never documented or converted into a physician’s order, staff and EMS proceeded with CPR as if the resident were Full Code, contrary to the POA’s expressed wishes.
Failure to Accurately Care Plan Admission Pressure Ulcer Within 48 Hours
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident, resulting in omission of critical wound information. Record review showed the resident was admitted on an unspecified date, and the Admission MDS documented that the resident had one unstageable pressure ulcer present on admission and required pressure ulcer/injury care. However, review of the resident’s baseline care plan, dated 02/19/26, revealed that staff did not document the presence of the pressure ulcer or the need for wound care. In an interview on 02/20/26 at 1:31 PM, the DON confirmed that the resident’s care plan did not indicate the pressure ulcer or wound care needs and stated that her expectation was for nurses to care plan wounds and necessary wound care within the first 48 hours of admission. This deficient practice could likely result in residents not receiving appropriate care and may place residents at risk of an adverse event or worsening of their condition after admission.
Failure to Develop Comprehensive Care Plans for Residents With Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the development and implementation of accurate, person-centered comprehensive care plans related to pressure ulcers for two residents. For one resident, the admission MDS dated 01/15/26 documented one unstageable pressure ulcer present on admission and two additional unstageable pressure injuries presenting as deep tissue injuries, also present on admission. The Care Area Assessment dated 01/21/26 indicated a need for pressure ulcer care. However, review of this resident’s care plan dated 01/16/26 showed that no care plan addressing pressure ulcers or the need for wound care had been developed. For the second resident, the admission MDS documented one unstageable pressure ulcer present on admission, and the Care Area Assessment dated 01/06/26 indicated a need for pressure ulcer care. The resident’s care plan, initiated on 12/28/25, did not include a care plan for pressure ulcers at that time; a pressure ulcer care plan was not added until 02/20/26. During an interview on 02/20/26 at 1:33 PM, the DON confirmed that comprehensive care plans for both residents did not include plans for their pressure ulcers and the need for wound care, despite the facility’s expectation that staff complete comprehensive care plans to include pressure ulcers and wound care needs.
Incomplete and Inaccurate Wound Care Documentation on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to wound care treatments for two residents. For one resident with a physician’s order dated 01/15/26 for daily wound care to the right buttock using normal saline, Medihoney, calcium alginate gauze, and a silicone bordered dressing, the Treatment Administration Record (TAR) for January 2026 showed no documentation that wound care was completed on 01/19/26, 01/21/26, and 01/23/26. For another resident with a physician’s order dated 01/01/26 for wound care to bilateral buttocks, including cleansing with normal saline, application of Sureprep to surrounding tissue, Medihoney to the wound bed, and coverage with a sacral silicone bandage, the January 2026 TAR contained no documentation of wound care from 01/02/26 through 01/23/26. During an interview on 02/20/26, the Wound Care Nurse stated she worked Monday through Friday and completed all wound care on those days. She reported that she did perform wound care for the first resident on 01/19/26, 01/21/26, and 01/23/26 but did not document these treatments on the TAR. She also stated she completed wound care for the second resident on 01/01/26, 01/02/26, 01/05/26 through 01/09/26, 01/12/26 through 01/16/26, and 01/19/26 through 01/23/26, but again did not document these treatments on the TAR. The Wound Care Nurse indicated that sometimes the unit nurse documented completion of wound care on the TAR, and acknowledged she should ensure that either she or the unit nurse documented the wound care as completed. The survey findings state that this failure to accurately document wound care had the potential to negatively impact the care staff provide due to inaccurate records.
Unlicensed Staff Member Provided Nursing Care and Demonstrated Incompetence
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid credentials to provide nursing services to all residents. An individual, identified as SM #1, was employed and worked as an LPN without holding a valid license, using false credentials that initially passed through the facility's background and license verification systems. During her employment, SM #1 demonstrated significant lapses in nursing skills, including improper handling of a resident's Foley catheter, which caused the resident pain, and multiple instances of incomplete documentation and medication errors. Staff interviews and disciplinary records revealed that SM #1 required extended orientation and frequent supervision due to her inability to complete competencies and perform basic nursing tasks independently. Further review showed that SM #1 was involved in several incidents, such as presenting a resident with unrecognized medications, attempting blood sugar checks on a non-diabetic resident, and being perceived as unskilled in IV administration. Other staff members reported that SM #1 often failed to perform her duties, required assistance from other nurses, and was frequently inattentive to resident care. Documentation issues, improper medication handling, and incomplete assessments were noted during her tenure. Staff expressed concerns about her proficiency and reported these issues to supervisors. The facility's investigation confirmed that SM #1 had worked for several months under false pretenses, and her lack of skills and credentials directly impacted the care provided to residents. The facility only discovered the falsification after multiple disciplinary actions and an incident involving improper Foley catheter care. SM #1 resigned when confronted with the investigation and refused to cooperate further.
Failure to Report Alleged Neglect and Medication Errors
Penalty
Summary
The facility failed to report allegations of neglect involving a resident who was affected by improper medication administration and incomplete care by a staff member who was later found to be working under false credentials. Specifically, the staff member left medications at the resident's bedside, administered medications that were not recognized by the resident, and attempted to perform procedures such as IV administration incorrectly. Documentation and required assessments for the resident were also incomplete, and concerns about the staff member's competence and actions were raised by both nursing and CNA staff to supervisors. Despite these incidents and staff concerns, the facility did not report the allegations of neglect to the State Agency as required. The Director of Nursing confirmed during an interview that the allegations related to the staff member's neglectful actions were not reported. The resident involved was receiving intravenous antibiotics and had incomplete admission and discharge documentation during their stay.
Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically lacking a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water system. This deficiency could potentially affect all 27 residents living in the facility. The facility's Water Management Policy, revised in September 2024, outlined the need for a Water Management Plan overseen by a team including center leadership, infection preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. However, interviews revealed that key personnel, including the Director of Maintenance and the Director of Nursing, were not aware of or involved in any activities or meetings related to water management and the prevention of Legionella growth. The Director of Maintenance, who has been in the position since October 2023, stated he was unaware of any responsibilities related to preventing the growth of Legionella or other waterborne pathogens, as these tasks were previously handled by an administrator who left in mid-2024. The Director of Nursing also confirmed a lack of involvement in meetings or actions regarding waterborne pathogen management. The current Administrator acknowledged that the Director of Maintenance should have a diagram of the water system and be aware of potential growth areas for pathogens, but he was not aware of the Water Management Plan team or involved in any related meetings. This lack of awareness and involvement among key staff members contributed to the facility's failure to implement an effective infection control program.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). This deficiency was identified during an interview and record review. The Director of Nursing (DON) revealed that the current IP had issues with her nursing license and has been on leave since January 10, 2025, due to these issues. Consequently, the DON has been performing the IP duties and is working towards obtaining her IP certification. A review of the former IP's time sheet confirmed that she last worked at the facility on January 10, 2025. This failure could potentially affect all 27 residents in the facility, as identified by the resident matrix provided by the Administrator.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop accurate, person-centered comprehensive care plans for three residents, which could result in staff being unaware of the residents' current and actual needs. For one resident, the care plan did not document the severe vision impairment and how staff would assist the resident, despite the admission record and Minimum Data Set (MDS) assessment indicating a severe vision impairment. Another resident's care plan failed to include their activity preferences, which were identified as very important during the MDS assessment interview. Additionally, the care plan for a third resident did not document the resident's functional level and the assistance needed to complete Activities of Daily Living (ADLs), even though the MDS assessment detailed substantial or maximal assistance required for various ADLs. The MDS Coordinator confirmed that the care plan should have included the resident's functional abilities, highlighting a gap in documentation and care planning.
Inadequate IDT Participation and Care Plan Updates
Penalty
Summary
The facility failed to meet care plan requirements for several residents due to inadequate participation of the Interdisciplinary Team (IDT) and failure to update care plans with current resident information. For one resident, the care plan meeting was attended only by the resident and a social services worker, lacking input from other essential team members. Another resident's care plan meeting included the dietary manager, family member, nurse navigator, social services staff, rehabilitation staff, and recreation staff, but no further meetings were held to ensure ongoing interdisciplinary input. Similarly, another resident's care plan meetings were inconsistently attended by necessary team members, with some meetings missing key participants such as the CNA and providers. Additionally, the facility did not revise a resident's care plan to reflect a new medical condition. The resident developed a stage I pressure ulcer on the right heel, which was documented in the nursing progress notes but not updated in the care plan. This oversight indicates a failure to ensure that the care plan accurately reflected the resident's current health status and necessary interventions, potentially impacting the quality of care provided.
Unlocked Treatment Carts Pose Safety Risk
Penalty
Summary
The facility failed to ensure the safety of residents on the East Unit by not securing treatment carts when not supervised by staff. During an observation, an IV treatment cart was found unlocked and open, containing sterile needles and intravenous catheters, with no staff present. This was confirmed by an RN who acknowledged that the cart should be locked when not in sight or control. Additionally, another treatment cart was observed unlocked and open, containing medications such as diclofenac, bacitracin, nystatin, mupirocin, silvasorb, and scissors, again with no staff present. An LPN confirmed that this cart was also supposed to be locked.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly store medications, as observed on the East Unit's medication cart, where a fish oil supplement, 1000 mg, was found to be expired since December 2024. This medication was intended to help reduce pain, improve morning stiffness, and relieve joint tenderness in people with rheumatoid arthritis. During an interview, RN #16 confirmed the expiration of the fish oil supplement and acknowledged that it should not have been present in the medication cart. Additionally, the Director of Nursing (DON) confirmed that expired medications should not be in the medication carts and that nurses are responsible for checking for expired medications during each shift.
Inadequate Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that the call light pull cords in residents' rooms were adequately equipped to allow residents to call for help. This deficiency was observed in the rooms of three residents, where the pull cords were not reachable unless the residents were in bed. One resident's wife reported that her husband was not cognizant enough to pull the cord, leaving him without an option to call for help. Another resident had a trash bag tied to the end of the call light cord, which was too short for him to reach, and he was unsure why the bag was there, except possibly to make the cord longer. A third resident was observed to be unable to reach the call light from his bed, and the Maintenance Director confirmed that the pull cords could not be reached if residents were not in bed. The Maintenance Director explained that the cords were shortened to prevent tangling, and there was no alternative method for residents who were not cognizant enough to pull the cord. The director also confirmed that the facility did not have a way to modify the pull cords for such residents, and some cords had bags tied to them to make them easier to grip. This practice could likely result in residents being unable to call for assistance when needed.
Failure to Provide Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide timely written notifications to residents and their representatives regarding transfers and discharges, as well as information on appeal rights and contact details for the Ombudsman. Specifically, five residents were affected by this deficiency. For one resident, the Power of Attorney (POA) only received a verbal notice of discharge and was not informed in writing about the discharge plan, appeal rights, or Ombudsman contact information. The POA had to independently seek out information to appeal the discharge, as the facility did not provide the necessary details. Additionally, the facility did not issue written transfer notices for residents who were sent to the hospital. In several cases, residents were transferred due to medical conditions such as altered mental status, gastrointestinal bleeding, low blood pressure, and elevated white blood cell count. The records for these transfers lacked documentation of written notices, and the facility's staff confirmed that they did not provide such notices to residents or their representatives. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's practice was to notify families of hospital transfers via phone, without providing written documentation. Furthermore, the Social Services department did not notify the Ombudsman of resident discharges or transfers, which is a required procedure. This lack of proper notification could lead to residents and their representatives being uninformed about their rights and the reasons for transfers or discharges.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written notices of the bed hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified for four residents who were reviewed for hospitalization. Specifically, the medical records of these residents did not contain any documentation of a written bed hold notice, which is required to inform residents or their representatives of how long their bed would be held during their absence. The deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the staff did not complete the bed hold notices prior to sending the residents to the hospital. The residents involved were sent to the hospital for various medical reasons, including altered mental status, gastrointestinal bleeding, abdominal pain, low blood pressure, elevated white blood cell count, and uncontrolled pain. The absence of written notices could result in residents or their representatives being unaware of the bed hold policy upon their return from the hospital.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, which could result in an inaccurate understanding of their needs. Resident #4 was admitted with a Stage II pressure ulcer on the coccyx, but the admission MDS incorrectly documented no unhealed pressure ulcers. Similarly, Resident #7 experienced a fall after admission, yet the MDS inaccurately recorded no falls since admission. Resident #11 was admitted with multiple wounds, including a pressure wound on the left heel and other ulcerations, but the MDS failed to document these conditions. Lastly, Resident #184 had Moisture Associated Skin Damage (MASD) due to incontinence, which was not recorded in the Medicare 5-Day MDS Assessment. Interviews with the Director of Nursing and the MDS Coordinator confirmed the discrepancies in the MDS assessments for these residents. The inaccuracies in the MDS documentation were identified through record reviews and staff interviews, highlighting a pattern of oversight in accurately capturing the residents' medical conditions and care needs upon admission. These deficiencies in documentation could potentially lead to inadequate care planning and interventions for the affected residents.
Failure to Document Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create accurate baseline care plans within 48 hours of admission for three residents, leading to potential risks of inadequate care. Resident #11 was admitted with multiple wounds, including cellulitis, sepsis, and MRSA infections, but the baseline care plan did not document these wounds or any interventions for their treatment. The MDS Coordinator confirmed that the baseline care plan should have included these details. Resident #184 was admitted with Moisture Associated Skin Damage (MASD) due to incontinence, but the baseline care plan did not document this condition or any interventions. The MDS Coordinator acknowledged that the baseline care plan was not completed within the required 48-hour timeframe and failed to include the MASD diagnosis, which was noted in the resident's progress notes. Resident #185 had several diagnoses, including severe protein-calorie malnutrition, dysphagia, and a PEG tube for enteral feeding. However, the baseline care plan did not document the dysphagia diagnosis, the presence of the PEG tube, or the specific diet and feeding orders. The MDS Coordinator confirmed these omissions, indicating that the baseline care plan should have included all relevant medical information and interventions.
Failure to Obtain and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders were obtained and implemented for a resident with a pressure ulcer. Upon admission, the resident had a Stage II pressure ulcer on the coccyx, as noted in the wound care consultation. Despite this, the facility did not have wound care orders in place for the resident's pressure ulcer from the time of admission until several days later. The Treatment Administration Record for December 2024 and January 2025 showed a lack of orders for the treatment of the pressure ulcer until January 11, 2025. Additionally, the facility's nursing progress notes indicated that staff did not consult with the facility provider to obtain necessary wound care orders for the resident's pressure ulcer, which was present upon admission. The Director of Nursing acknowledged that nursing staff failed to identify wounds upon admission and did not obtain orders for the pressure ulcer, which was against the facility's expectations. This deficiency could lead to inconsistent interventions and worsening of the pressure ulcer.
Lack of Physician Order and Clinical Justification for Condom Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with a condom catheter had a physician's order and a documented clinical condition justifying its use. During an interview, the resident stated that he had a catheter to streamline the process of elimination, despite being continent of bowel and bladder. An observation confirmed the presence of a catheter, but a review of the resident's physician orders and medical record revealed no order or documented clinical condition necessitating the use of a condom catheter. The Director of Nursing confirmed the absence of an order or clinical documentation, acknowledging that the facility's expectation is for all residents to have orders and clinical reasons for catheter use.
Failure to Change Nasal Cannula as Scheduled
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not changing the nasal cannula within the required 7-day period. During an observation, it was noted that the resident's nasal cannula was not dated, indicating when it had last been changed. The resident had a physician's order for continuous oxygen at 2 liters via nasal cannula. The Director of Nursing (DON) stated that nasal cannulas are typically changed weekly on Sundays, and a piece of tape with the date is used to document the change. However, a Certified Nursing Assistant (CNA) confirmed that the resident's cannula did not have a date, and she could not verify if it had been changed as per the schedule. This oversight could lead to the nasal cannula becoming obstructed, non-functional, and unsanitary, potentially affecting the resident's oxygen supply.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic medication without a medical necessity. Specifically, a resident was administered Remeron, an antidepressant, for muscle weakness, which is not an appropriate medical diagnosis for the use of this medication. The resident's admission record indicated diagnoses of cognitive communication deficit, other symbolic dysfunctions, and severe dementia without behavioral, psychotic, mood, or anxiety disturbances, none of which justify the use of Remeron. The physician's order dated January 11, 2025, prescribed Remeron 15 mg at bedtime for muscle weakness, and the Medication Administration Record confirmed that the resident received this medication every evening starting from that date. During an interview, the Director of Nursing confirmed the order for Remeron for muscle weakness and acknowledged that the resident did not have a medical diagnosis appropriate for the use of this medication. This oversight could lead to the resident receiving unnecessary medication, increasing the risk of adverse side effects.
Deficiencies in Wound Care and Skin Condition Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, leading to deficiencies in wound care and skin condition management. For one resident, the facility did not implement convalescent care orders for multiple wounds upon admission. The resident had several wounds, including ulcerations and a surgical wound, which required specific wound care treatments. However, the staff did not document any wound care orders or treatments between the resident's admission and several days later, nor did they assess the resident's skin upon admission. This lack of documentation and care could have led to the staff and physician being unaware of changes in the resident's condition. Another resident developed Moisture Associated Skin Damage (MASD) due to incontinence, but the facility failed to notify the provider or document any treatment for this condition. The resident's progress notes consistently recorded the presence of MASD over several days, yet there was no documentation of provider notification or treatment orders in the medical record. Interviews with staff confirmed that the nurse should have assessed the resident's skin, contacted the provider for orders, and documented any communication and treatment. The deficiencies highlight a failure in the facility's processes for implementing care orders and managing changes in residents' conditions. The lack of documentation and communication with providers regarding wound care and skin conditions could lead to worsening of residents' health. The facility's staff did not follow established protocols for assessing and documenting care, which are critical for ensuring residents receive appropriate treatment.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of investigations regarding alleged medication diversion and injuries of unknown origin to the State Agency within the required five-day period. This deficiency was identified through record reviews and interviews. In one case, a resident was sent to the emergency room due to a nosebleed and was found to have rib fractures and a compression fracture of the Thoracic 10 vertebrae. Despite efforts to determine the cause, no explanation was found, and the facility did not document that a follow-up report was submitted to the State Agency within the required timeframe. In another incident, the facility reported missing narcotics, with the initial incident occurring on a specified date. The medication count on the Emergency Kit was found to be inaccurate, and new interventions were developed to secure the kit. However, the facility again failed to document that a follow-up report was submitted to the State Agency within five days of the incident. The Director of Nursing confirmed the lack of documentation for both incidents during an interview.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data that included the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides responsible for resident care per shift. During an observation on January 30, 2025, it was noted that the nurse staffing data posted at the front entrance did not include the required information for the day. In an interview, the Director of Nursing (DON) confirmed that the night shift nurse is responsible for posting this data, which should include the total number of staff scheduled for each shift and the number of hours each nursing staff member is scheduled to work.
Failure to Develop Individualized Discharge Plans
Penalty
Summary
The facility failed to develop care plans addressing the individualized discharge goals and needs for three residents (R #11, R #12, and R #13) reviewed for discharge planning. Record reviews revealed that the care plans for these residents, dated 01/19/24, 03/06/24, and 04/01/24 respectively, did not include documentation of their discharge goals and needs. During an interview on 05/01/24, the Social Services (SS) staff confirmed the absence of such documentation in the residents' care plans and charts.
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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