Aztec Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Aztec, New Mexico.
- Location
- 500 Care Lane, Aztec, New Mexico 87410
- CMS Provider Number
- 325071
- Inspections on file
- 25
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Aztec Healthcare during CMS and state inspections, most recent first.
A resident with a MOST form indicating DNR status was found unresponsive without pulse or respirations. Staff, relying on the EHR top banner that incorrectly listed the resident as full code, initiated CPR, applied an AED, and continued resuscitation until EMS arrived and the resident was pronounced deceased. The resident’s baseline care plan lacked code status, and the MOST form in the EHR documents section was not reviewed during the emergency. Interviews showed that staff depended on the EHR top banner for code status, while responsibilities for updating MOST forms and corresponding physician orders were unclear. A facility-wide audit later revealed multiple residents with discrepancies between advance directives and code status orders, as well as missing or incomplete advance directive documentation.
Surveyors found that two residents were receiving clinical interventions without required physician orders. One resident with serious neurological diagnoses was observed using O2 via nasal cannula with an O2 concentrator in the room, but record review showed no corresponding physician order, despite facility policy requiring an order specifying flow rate, method, usage, and indication. Another resident was observed with a Foley catheter collection bag hanging from the bed, yet no physician order for the catheter was present in the record, contrary to the facility’s catheter policy requiring medical necessity and valid justification. An LPN, the ADON, and the DON all confirmed the absence of appropriate orders for these treatments.
A resident with peripheral vascular disease, muscle weakness, CHF, and an active wound infection was on Enhanced Barrier Precautions (EBP) with posted signage requiring PPE use for direct care. Facility policy required targeted gown and glove use to prevent transmission of multidrug-resistant organisms. Despite this, a CNA was observed providing direct care to the resident without any PPE and later acknowledged that PPE should have been worn, while the DON stated the expectation that all staff follow EBP guidelines.
A resident who required assistance with mobility developed a coccyx/sacral wound that was identified but not promptly followed by wound care orders, and later received inconsistent wound treatments with multiple undocumented omissions on the TAR. Weekly wound assessments were missed, and the wound progressed from MASD to Stage 3 and then Stage 4 with infection, ultimately requiring hospital care for osteomyelitis and sepsis. Staff also failed to timely recognize and act on a new left ischial/buttock wound that had been noted on a skin check but not communicated to the WCN, and this wound was not formally assessed or treated until it was large, mostly slough, and boggy. CNAs reported seeing wounds and odor and stated they informed nurses, while facility leadership acknowledged missed notifications, incorrect wound location documentation, poor understanding of skin assessment processes, and failure to consistently follow and document wound care orders.
A resident with unspecified dementia and cognitive symptoms had an MDS assessment in which staff indicated that a Brief Interview for Mental Status (BIMS) should be conducted, but no responses were entered in the BIMS section. The MDS Coordinator, who was responsible for completing the assessment, acknowledged that MDS assessments were expected to be fully completed and that sections should not be left unanswered.
A resident with a history of liver cirrhosis and other conditions experienced a change in condition, leading to lab tests and a chest X-ray. The facility failed to notify the physician of critical results, including low potassium and signs of pneumonia, resulting in delayed treatment. The resident was later found unresponsive and could not be revived. This incident was identified as Past Non-Compliance Immediate Jeopardy.
A resident with a history of liver cirrhosis and esophageal varices experienced a change in condition, prompting diagnostic tests that revealed critically low potassium levels and pneumonia. The facility failed to notify the physician of these results, delaying treatment. The resident's condition worsened, and he was found unresponsive and breathless, leading to his death despite emergency care efforts. The incident was identified as past non-compliance with immediate jeopardy.
A resident with a left lower foot amputation and other medical conditions required assistance for toileting. Despite this, a CNA instructed the resident to use her brief instead of assisting her to the toilet. The care plan did not indicate the resident's non-weight bearing status, leading to a deficiency citation.
The facility failed to protect residents from abuse and neglect, resulting in emotional trauma and physical abuse. A resident experienced emotional trauma when her deceased roommate's body was not promptly removed, leading to panic attacks. Multiple residents reported physical abuse by the same CNA, including rough handling and yelling, resulting in bruising and police involvement. The facility's failure to prevent these incidents constitutes a significant deficiency in care.
The facility failed to report incidents of employee-to-resident abuse/neglect to the State Agency and did not submit required follow-up reports. One incident involved a resident found intoxicated, with allegations of CNAs drinking with the resident. Despite reporting some incidents, follow-up reports were not transmitted due to an error.
Two CNAs neglected their duties during a night shift, spending hours outside in a car with a resident who later returned intoxicated. The charge nurse's attempts to intervene were ignored, leading to inadequate care for residents on their hallways. The day shift staff found many residents in soiled conditions, highlighting the impact of the CNAs' absence.
The facility failed to ensure the safety of two residents, leading to potential accident hazards. One resident's fall mats were not removed when not in use, posing a tripping hazard. Another resident eloped due to inadequate monitoring of a wanderguard, despite a physician's order for regular checks. The resident was later found and returned unharmed.
A resident was observed self-administering medication without proper authorization or supervision, as the facility failed to have the IDT assess and document the resident's ability to self-administer. The care plan and physician's orders did not reflect permission for self-administration, and the DON confirmed that staff should have been present to observe the medication intake.
A facility failed to include fall interventions in a resident's care plan, despite the resident's multiple diagnoses and the use of fall mats in their room. Observations showed fall mats were used, but interviews with the ADON and DON revealed that these were not documented in the care plan, indicating a lack of comprehensive planning for fall prevention.
The facility failed to ensure that collection bags were kept off the floor for two residents, contrary to their infection control policy. One resident had a urinary infection and was on antibiotic treatment. The ADON confirmed that collection bags should be kept at gravity level, hooked onto the chair or bed.
The facility failed to create an accurate Baseline Care Plan within 48 hours of admission for a resident. The care plan did not include necessary catheter care, which was confirmed by the ADON during an interview. The omission was later corrected.
Failure to Honor DNR Due to Inaccurate EHR Code Status and MOST Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s advance directives and code status were accurate and consistent within the electronic health record (EHR), resulting in resuscitative efforts that conflicted with the resident’s documented wishes. The resident was admitted with diagnoses including encephalopathy, type 2 diabetes mellitus, and shock. Review of the resident’s baseline care plan showed that the resident’s code status was not included in the plan of care. A MOST form completed for the resident indicated a do not resuscitate (DNR) status, but this information was not reflected in the EHR’s top banner, which instead showed the resident as a full code. When a certified nursing assistant entered the resident’s room to deliver a dinner tray, the resident was found unresponsive in a wheelchair, without a pulse or respirations. Nursing staff responded, moved the resident to the floor, and initiated CPR. Staff called 911, applied an AED, and continued chest compressions and ventilations with an Ambu bag until EMS arrived. The AED did not deliver a shock, but CPR was continued for approximately 17 minutes until a physician pronounced the resident deceased. The LPN who initiated CPR stated she had checked the EHR top banner and saw the resident listed as full code and did not review the MOST form before starting resuscitation. Interviews with facility staff revealed that the EHR top banner was relied upon by nursing and CNA staff to determine a resident’s code status in an emergency, and that the MOST form was stored separately in the documents section of the EHR. The DON stated it was the social services director’s responsibility to ensure MOST forms were updated in the EHR, while the social services director stated that MOST forms were uploaded after being signed by a physician and that the form and code status did not become active until that signature. Other staff, including the ADON, CNAs, and an RN, confirmed that code status should be accurate on the EHR top banner and match the MOST form, but in this case the resident’s DNR status on the MOST form did not match the full code status displayed in the EHR. Surveyors identified this discrepancy and the failure to honor the resident’s DNR status as an Immediate Jeopardy situation. Further record review showed that the facility’s comprehensive advance directive audit identified multiple residents with discrepancies between documented advance directives, including MOST forms, and physician orders for code status, as well as residents with missing or incomplete advance directive documentation. This demonstrated that the issue extended beyond a single resident and involved systemic problems with ensuring that residents’ advance directives were accurately reflected in physician orders and the EHR.
Failure to Obtain Physician Orders for Oxygen Therapy and Foley Catheter Use
Penalty
Summary
The facility failed to follow its own oxygen administration policy and professional standards of practice for one resident when oxygen therapy was provided without a physician’s order. The facility’s Oxygen Administration Policy dated 06/2020 requires a physician’s order to initiate oxygen therapy, including the flow rate, method of administration, usage, and indication. Record review of one resident’s face sheet showed admission with diagnoses of malignant neoplasm of the brain and epilepsy. Review of the resident’s physician orders dated 04/06/26 revealed no order for oxygen use. Despite this, surveyors observed the resident on two occasions lying in bed using oxygen via nasal cannula with an oxygen concentrator present in the room. In interviews, the ADON and DON both confirmed that the resident did not have a physician’s order for oxygen and stated their expectation that all residents on oxygen therapy have such an order specifying the correct liter flow. The facility also failed to follow its catheter policy and professional standards of practice for another resident who was using an indwelling Foley catheter without a physician’s order. The Catheter Policy dated 03/2020 states that residents are not to be given indwelling catheters unless medically necessary and with valid medical justification, and that residents should receive appropriate care and services to prevent infections. Record review of this resident’s face sheet showed admission to the facility, and review of physician orders dated 04/06/26 revealed no order for a Foley catheter. During observation, surveyors saw a catheter collection bag hanging from the resident’s bed, indicating Foley catheter use. In interviews, an LPN and the DON both confirmed there was no physician’s order for the Foley catheter, and the DON stated that if a resident does not have a physician’s order for a Foley catheter, the resident could develop complications in care.
Failure to Follow Enhanced Barrier Precautions and PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program by not following its own Enhanced Precautions Infection Policy, dated 04/01/2024, which required the use of appropriate PPE, including targeted gown and glove use, to prevent transmission of multidrug-resistant organisms. Signage posted at the entrance of one resident's room indicated the resident was on Enhanced Barrier Precautions (EBP) and that staff were required to wear PPE when providing care. The Director of Nursing stated it was the expectation that all staff providing care follow EBP guidelines. The resident involved was admitted on 02/27/2023 with diagnoses including peripheral vascular disease, muscle weakness, and congestive heart failure, and had an active diagnosis of a wound infection per the Comprehensive MDS dated 03/06/2026. Physician orders dated 01/20/2026 directed cleansing of both lower extremities with normal saline, application of Silvadene 1% cream, and wrapping with kerlix gauze, with instructions to report any worsening of the wound. On 04/07/2026 at 9:06 AM, a CNA was observed providing direct care to this resident without wearing any PPE, despite the posted EBP signage. In a subsequent interview at 9:11 AM, the CNA acknowledged providing care without PPE and stated she should have worn PPE when caring for the resident.
Failure to Initiate, Monitor, and Document Pressure Ulcer Care Leading to Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and consistent pressure ulcer treatment and monitoring for a resident, resulting in the development and worsening of pressure ulcers. The resident was admitted without documented pressure ulcers but was identified on 10/28/25 as having a new coccyx/sacral wound with blood noted on the gown. Despite this identification, there were no wound care orders in place from 10/28/25 through 11/06/25, and the wound was initially documented only as a skin tear or MASD in weekly skin checks without detailed description. The Wound Care Nurse later confirmed that no orders or treatments were completed for the coccyx/sacral wound from 10/29/25 to 11/07/25, and she was not made aware of the wound until 11/04/25. Once wound care orders were initiated in November, staff failed to consistently administer and document the ordered treatments. The Treatment Administration Records show multiple dates in November, December, and January where wound care for the coccyx/sacral wound was not documented as completed, and no codes were entered to indicate refusal or other reasons for omission. Weekly wound assessments by the Wound Care Nurse were also missed, including the week of 11/10/25, and subsequent assessments documented progression from MASD to Stage 3 and then Stage 4 pressure ulcer with heavy purulent exudate, slough, tunneling, and signs of infection. The resident’s NP and MD notes documented an infected coccyx/sacral wound requiring debridement and antibiotics, and the resident was ultimately transferred to the hospital with osteomyelitis and sepsis related to the coccyx/sacral pressure ulcer. The facility also failed to timely identify and treat a new left ischial/buttock wound. A weekly skin check on 12/26/25 documented a pressure wound to the left buttock, but the Wound Care Nurse later stated she was unaware of this finding and did not know how long the left ischial wound had been present. The Assistant DON acknowledged that the wound did not develop overnight and had been missed by staff. The left ischial wound was not documented on January weekly skin checks, and wound care orders for this area were not obtained until 01/14/26, after the Wound Care Nurse observed sores on the resident’s backside. The Wound Care Nurse’s assessment on 01/15/26 described the left ischial wound as unstageable, large, mostly slough, and boggy, and the TAR again showed missed and undocumented treatments for both the coccyx/sacral and left ischial wounds. CNAs reported seeing wounds and redness, including a wound with odor, and stated they informed nurses, while the ADON and Wound Care Nurse confirmed that staff failed to notify them promptly and that nurses did not understand or follow skin assessment and wound care processes. Throughout the period, the resident required assistance with mobility and repositioning and experienced significant pain with turning, sometimes refusing care, air mattress use, and IV antibiotics. However, the care plan entries documenting the resident’s self-determination and refusals were initiated later, and there was no consistent documentation on the TAR to show when wound care was refused versus not provided. The facility’s leadership, including the ADON and DON, acknowledged that wound care orders were not followed or documented as expected, that wound locations were initially documented incorrectly, and that the left ischial wound should have been identified and treated sooner. The cumulative inactions included delayed initiation of wound care after initial wound identification, inconsistent performance and documentation of ordered treatments, missed weekly wound assessments, and failure to timely recognize and report a new pressure wound, all of which led to the resident’s pressure ulcers worsening and requiring hospitalization for advanced wound care and surgical debridement.
Incomplete MDS BIMS Section for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an accurate and complete Minimum Data Set (MDS) assessment for one resident. Record review showed that this resident was admitted with diagnoses including unspecified dementia with behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness. Review of the resident’s MDS, dated as noted in the record, showed that staff indicated a Brief Interview for Mental Status (BIMS) should be conducted, but no answers were documented in the BIMS section. In an interview, the MDS Coordinator confirmed she was responsible for completing this resident’s MDS assessments and stated that her expectation was that the assessments be fully completed and that staff should not leave sections unanswered. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to notify the physician of a resident's critical lab results and chest X-ray findings following a change in condition. The resident, a male with a history of liver cirrhosis, esophageal varices, and a chronic left arm deformity, was admitted to the facility with concerns of a gastrointestinal bleed. He experienced a change in condition characterized by a persistent unproductive cough, prompting the medical provider to order a chest X-ray, CBC, and CMP. The results, which indicated abnormalities such as low potassium and signs of pneumonia, were received by the facility but were not communicated to the physician in a timely manner. The staff member who received the lab results emailed them to the Director of Nursing and the Assistant Director of Nursing and left a hard copy at the nurse's station. However, the Assistant Director of Nursing admitted that the results were not sent to the physician as required. The physician was not informed of the critical lab results, including the low potassium level, which was particularly concerning given the resident's medication regimen that included furosemide without a potassium supplement. The physician only became aware of the resident's condition after a subsequent change in condition, at which point antibiotics were ordered for suspected pneumonia. The delay in notifying the physician likely resulted in delayed treatment for the resident's pneumonia and contributed to the resident's death. The resident was found unresponsive and breathless, and despite emergency care, he could not be revived. The physician later confirmed that had he been notified of the lab results earlier, he would have taken steps to address the resident's pneumonia and low potassium levels. This incident was identified as Past Non-Compliance Immediate Jeopardy, indicating a serious deficiency in the facility's communication and response protocols.
Failure to Notify Physician of Critical Lab Results Leads to Resident's Death
Penalty
Summary
The facility failed to notify the physician of critical diagnostic results for a resident following a change in condition, which likely resulted in delayed treatment for pneumonia and contributed to the resident's death. The resident, a male with a history of liver cirrhosis, esophageal varices, and a chronic left arm deformity, was admitted to the facility with concerns of a gastrointestinal bleed. He was initially treated with antibiotics for possible pneumonia. A change in condition was noted when the resident developed a persistent unproductive cough, prompting the medical provider to order a chest X-ray, CBC, and CMP. The diagnostic results, which included critically low potassium levels and indications of pneumonia, were faxed to the facility but were not communicated to the physician in a timely manner. The results were received by a staff member who emailed them to the DON and ADON and left a hard copy at the nurse's station. However, the physician was not notified of these results, and no new orders were made for the resident until several days later when the physician was finally informed of the chest X-ray results. By this time, the resident's condition had worsened, and he was found unresponsive and breathless, leading to his death despite emergency care efforts. Interviews with facility staff revealed that the ADON acknowledged the failure to notify the physician of the abnormal lab results and the need for immediate medical intervention. The physician confirmed that had he been notified, he would have ordered appropriate treatments, including antibiotics and potassium supplements. The incident was identified as past non-compliance with immediate jeopardy, indicating a serious lapse in the facility's duty to provide timely and appropriate care to the resident.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to assist a resident in maintaining their ability to perform activities of daily living (ADLs), specifically toileting, which led to a deficiency. The resident, who had a left lower foot amputation and other medical conditions such as Type II diabetes and diabetic neuropathy, required partial, moderate assistance for toileting as per their admission Minimum Data Set (MDS). However, the care plan did not indicate that the resident was non-weight bearing with her legs. A grievance was filed when the resident reported that a Certified Nursing Assistant (CNA) instructed her to use her brief instead of being assisted to the toilet, which the resident did not want to do. Interviews and written statements revealed that the CNA was aware of the resident's fall risk and non-weight bearing status but opted to let the resident use the bed for bowel movements, believing it was easier for her. Another CNA confirmed that the resident frequently requested to be transferred to the toilet but was often provided a bedpan or had her brief changed instead. The Corporate Nurse acknowledged that the resident should have been given the opportunity to use the toilet, as she was not on a non-weight bearing status. The facility's failure to provide appropriate assistance for toileting led to the deficiency being cited.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in emotional trauma and physical abuse for several residents. One resident, who was cognitively intact, experienced emotional trauma when her deceased roommate's body was not promptly removed from their shared room. Despite requesting the removal of the body, the staff did not comply, leaving the resident with panic attacks and anxiety about future roommates. The Assistant Director of Nursing (ADON) acknowledged the incident but did not take immediate action to address the resident's concerns. Physical abuse was reported by multiple residents involving the same Certified Nurse Aide (CNA). One resident reported being kicked and hit by the CNA, although no injuries were noted at the time. Another resident experienced rough handling and was yelled at by the CNA for using the call light, resulting in bruising. The police were involved, and the resident showed the officer the bruises, which were documented in a police report. The CNA was suspended pending investigation but returned to work before further allegations surfaced. A third resident was found with significant bruising on her right forearm, which was suspected to have been caused by the same CNA. The bruising was consistent with aggressive handling, and there was no medical explanation for the injury. The facility's Regional Nurse Consultant confirmed that the CNA had worked with the resident independently, and no incidents were reported by other staff. The facility's failure to prevent these incidents and protect residents from abuse and neglect constitutes a significant deficiency in care.
Failure to Report and Follow-Up on Abuse/Neglect Incidents
Penalty
Summary
The facility staff failed to report incidents of employee-to-resident abuse/neglect to the State Agency (SA) and did not submit the required five-day follow-up reports for several residents. Specifically, the management received allegations involving multiple residents and staff members, including an incident where a resident was found intoxicated with a blood alcohol content of 0.209%. The Assistant Director of Nursing (ADON) was informed that two Certified Nursing Assistants (CNAs) were involved in drinking alcohol and smoking cigarettes with the resident during the night shift. Despite these serious allegations, the ADON did not report the incident to the SA. Additionally, the facility reported incidents involving other residents and CNAs to the SA but failed to submit the necessary five-day follow-up investigations. These incidents involved interactions between CNAs and residents, but the follow-up reports were not transmitted due to an error in the online reporting system. The lack of proper reporting and follow-up documentation could impact the safety and well-being of the residents involved.
Neglect of Duties by CNAs Leads to Resident Intoxication and Inadequate Care
Penalty
Summary
The facility failed to meet professional standards of quality for residents on the 100 and 200 hallways, as evidenced by the actions and inactions of staff members during a night shift. A resident was reported missing for several hours and later returned to the facility with a blood alcohol content of 0.209%. It was discovered that two CNAs, along with the resident, were absent from their duties for extended periods, spending time in a car outside the facility. Despite attempts by the charge nurse to address the situation, the CNAs ignored her and continued their activities, which included smoking and potentially drinking alcohol. The neglect of duties by the CNAs resulted in inadequate care for the residents on their assigned hallways. When the day shift staff arrived, they found that many residents had not been attended to, with some being left in soiled conditions. The charge nurse and other staff members expressed frustration over the CNAs' absence, which left the remaining staff to cover their responsibilities. The incident was reported to the ADON, who confirmed the CNAs' neglect and the resident's intoxication.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of two residents, leading to potential accident hazards. For one resident, the staff did not remove fall mats from the floor when the resident was not in bed, which restricted the resident's movement in her wheelchair and posed a tripping hazard. The Assistant Director of Nursing (ADON) acknowledged that the mats were left on the floor to prevent injury from falls but did not consider them a fall hazard themselves. For another resident, the facility did not adequately monitor the placement and function of a wanderguard, a device intended to prevent elopement. Despite a physician's order to check the wanderguard every shift, the resident was able to leave the facility unnoticed with a visitor. The ADON admitted that the resident did not allow staff to check the wanderguard, and it was discovered missing after the resident had eloped. The resident was eventually located and returned to the facility unharmed.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to have the Interdisciplinary Team (IDT) determine if a resident could self-administer medication, which is a necessary step to ensure the safety and appropriateness of self-medication. The care plan for the resident, dated 05/05/24, did not indicate that the resident was allowed to self-administer medication. Additionally, the resident's active physician's orders as of 06/04/24 did not include an order for self-administration of medications. This oversight in documentation and assessment by the IDT led to a situation where the resident was self-administering medication without proper authorization or supervision. During an observation on 06/04/24, the resident was seen taking medication unsupervised while lying in bed, with no staff present. The resident confirmed in an interview that she preferred to take her medications after eating and that staff left the medications with her to take at her convenience. The Director of Nursing (DON) confirmed that the resident's care plan and physician's orders did not authorize self-administration of medication, and it was expected that staff should observe the resident taking medications. This lack of adherence to protocol could result in inappropriate or incorrect self-administration of medication by the resident.
Failure to Document Fall Interventions in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as R #14, which included necessary fall interventions. The resident was admitted with multiple diagnoses, including cerebral infarction, abnormal posture, unsteadiness on feet, muscle weakness, unspecified pain, and wedge compression fractures of the T9 and T10 vertebrae. Observations on different dates revealed that fall mats were placed on the floor in the resident's room, but the care plan, dated 02/13/24, did not document the use of these fall mats as a fall prevention intervention. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the staff routinely left fall mats on the floor to prevent injuries from falls, even when the resident was out of bed. However, the use of these fall mats was not documented in the resident's care plan, indicating a lack of comprehensive planning to address the resident's fall risk. This oversight could potentially result in the resident not receiving the necessary care to achieve their highest practicable level of well-being.
Improper Infection Control Practices
Penalty
Summary
The facility failed to provide proper infection control practices when staff did not ensure that collection bags were kept off the floor for two of three residents. The facility's policy, revised in June 2020, instructed staff to ensure that collection bags do not touch the floor at any time. However, observations revealed that the collection bags of two residents were lying on the floor. One resident had a urinary infection and was on antibiotic treatment, with lab results showing the presence of pseudomonas putida and enterococcus faecalis in the urine. The Assistant Director of Nursing confirmed that collection bags should not lie on the floor and should be kept at gravity level, hooked onto the chair or bed.
Failure to Create Accurate Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate Baseline Care Plan within 48 hours of admission for one resident. The resident was admitted on an unspecified date, and the care plan dated 1/31/24 did not include necessary catheter care. This omission was confirmed by the Assistant Director of Nursing (ADON) during an interview on 03/05/34, who acknowledged that the staff missed including catheter care in the baseline care plan and subsequently added it on 3/4/24.
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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