La Vida Llena
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 10501 Lagrima De Oro Ne, Albuquerque, New Mexico 87111
- CMS Provider Number
- 325035
- Inspections on file
- 18
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at La Vida Llena during CMS and state inspections, most recent first.
Surveyors found multiple expired food items stored in both the main kitchen and the serving kitchen, including drinks, salsa, boiled eggs, cheese slices, spinach, and yogurt, all past their labeled use-by or expiration dates. The Dietary Manager confirmed the items were expired and acknowledged that staff are expected to monitor dates and discard outdated foods, noting that residents are at risk of foodborne illness if served expired items.
The facility failed to prevent avoidable accidents for two residents by not following established transfer and fall-prevention measures. One resident with dementia and Alzheimer’s disease, care planned for a one-person stand-and-pivot transfer with a gait belt, was instead transferred with a mechanical Sara lift, resulting in a witnessed fall with head injury and a skin tear. Another resident with aphasia, dementia, and Alzheimer’s disease had a history of multiple falls and was care planned for fall mats on both sides of the bed, but required fall risk assessments were not completed for several months, and the fall mat was observed stored against the wall while the resident was in bed. The DON and staff acknowledged that transfer requirements and fall assessment protocols were not followed as expected.
Surveyors found that staff failed to protect resident PHI on the 600-unit. A paper listing resident names and vital signs was left unattended and visible on a medication cart in a common area, and the cart’s computer screen was left on and unattended in a hallway, displaying full resident names, prescribed medications, and allergies. On another occasion, a daily unit census with resident names and room numbers was left uncovered and visible on the same cart. An LPN and an RN each confirmed that the exposed information was PHI and acknowledged it was visible to anyone passing by, and the DON stated the expectation is that PHI should not be open for anyone to view.
A cognitively intact resident with Type 1 DM, anxiety, and depression was placed on a Wanderguard and restricted from leaving the unit despite facility policies stating that restraining ambulatory residents simply to prevent wandering is unacceptable and that elopement applies to those with impaired cognition. The resident’s MDS showed a BIMS of 15 with no wandering behaviors, a MOCA score of 28/30, and a neuropsychological evaluation with negative dementia screening, yet the care plan labeled the resident as an elopement risk and called for a security bracelet. The Medical Safety Device Assessment for the Wanderguard was incomplete, and there was no documented evidence of unsafe wandering, elopement attempts, or implementation of less restrictive interventions before applying the device. The resident reported feeling isolated, depressed, and like a “caged animal” due to the Wanderguard and inability to attend preferred on-campus activities, while multiple staff acknowledged the resident’s emotional distress and conflictingly described the rationale for the device as related to diabetes management and perceived safety concerns.
The facility did not complete required significant change in condition MDS assessments for two residents who began hospice services. One resident with multiple conditions, including dementia and Alzheimer’s disease, was documented as starting hospice, yet a subsequent quarterly MDS did not reflect hospice services. Another resident with dementia, heart disease, NSTEMI, peripheral vascular disease, and hyperlipidemia started hospice, but no significant change MDS was completed afterward. The MDSC acknowledged that a significant change MDS is required when a resident begins hospice and confirmed it was not done for these two residents.
Surveyors found multiple failures in medication security and storage on one unit, including unlocked and unattended medication carts in resident areas containing scheduled oral medications, eye drops, inhalers, and injectables, as well as a loose, unidentified pill in a cart drawer and expired viral transport testing swabs stored in the medication room. Nursing staff, including an RN, an LPN, and the DON, acknowledged that carts are expected to be locked when unattended, free of loose medications, and that expired supplies should not be kept in medication storage areas.
A resident with multiple cardiovascular conditions was prescribed Clopidogrel, an antiplatelet, as documented in physician orders and the MDS, but the care plan incorrectly identified the resident as receiving anticoagulant therapy and at risk from blood-thinning medications. During observation, the resident had bruising on both hands and reported being on an anticoagulant, and the DON later confirmed that the medical record did not show an anticoagulant order and that the resident had been care planned for the wrong type of medication.
Surveyors identified that the facility did not meet professional standards when one resident receiving hospice services lacked an active physician order for hospice despite documentation of hospice care in the record, and another resident with DM2 did not receive the ordered 1,000 mg dose of Metformin when an RN administered only 500 mg. The DON confirmed that a physician order is required for hospice admission and that nursing staff must follow physician orders and administer correct medication doses.
A resident with MS and identified nutritional risk, including weight loss and increased needs related to wound care, had physician orders for a regular diet, Prostat supplement, and monthly weights for routine monitoring. Weight records showed only a few documented weights over several months, with no entries after early July, and a later nutritional evaluation noted a 3% weight loss compared to a prior weight. The MDS assessment lacked a current documented weight, and the care plan called for weighing per physician orders. The DON confirmed that the last recorded weight was months earlier, that monthly weights should have been obtained or refusals documented, and that the resident’s weights were not being consistently monitored.
A resident with Type 1 DM on long-term insulin therapy had duplicate bedtime orders for Insulin Glargine-yfgn, each for 15 units, active over several days. Due to these unresolved duplicate orders and failure to accurately follow the facility’s medication administration policy, the resident was given 17 units instead of 15 units of long-acting insulin, resulting in multiple days of low blood sugars before the error was identified by the physician. The DON later confirmed that a medication error occurred and that the resident had received duplicate insulin orders and incorrect dosing.
An LPN failed to sanitize blood pressure cuffs after using them on a resident who was on Enhanced Barrier Precautions and then proceeded to document medication administration on a computer at the medication cart without disinfecting the equipment. In a follow-up interview, the LPN admitted forgetting to clean the cuffs and acknowledged that facility policy requires cleaning the equipment before leaving the resident’s room. This lapse in infection control was identified by surveyors as likely to result in transmission of infectious agents between residents and staff.
A resident with severe cognitive impairment was exploited by a sales consultant who accessed her financial information, purchased her home below market value, and fraudulently obtained a refund for her hearing aids after her death by misrepresenting himself as her grandson. The facility lacked controls over staff and visitor access, did not maintain visitor logs, and failed to ensure concerns about the consultant's actions were reported or investigated, resulting in misappropriation of the resident's property.
The facility failed to maintain sanitary food storage conditions, with raw salmon improperly stored above salsa, risking cross-contamination. Expired salad dressings and an unsealed bottle of liquid smoke were found in dry storage. The Director of Dining Services and kitchen staff acknowledged these practices were against protocol.
A resident's oxygen nasal cannula was observed dragging on the floor as she moved in her wheelchair, violating infection control protocols. The resident, who required continuous oxygen for hypoxia, was unaware of the issue until informed. The facility's Infection Preventionist RN acknowledged the risk of contamination from the floor.
Expired Food Items Stored and Available for Use in Facility Kitchens
Penalty
Summary
Surveyors identified a deficiency in food storage and service sanitation when expired food items were found in both the main kitchen and the serving kitchen. During an initial tour of the main kitchen, a small refrigerator contained two pink drinks in covered cups marked with a use-by date that had passed, and a large refrigerator contained one container of salsa, one container of boiled eggs, and one individual package of cheese slices, all labeled with use-by dates that had already expired. In a follow-up observation of the main kitchen, the large refrigerator was found to contain a box of fresh spinach with a use-by date that had passed. In the small serving kitchen refrigerator, surveyors observed one container of salsa and one medium-sized container of plain yogurt, both beyond their use-by or expiration dates. The Dietary Manager confirmed these foods were expired and acknowledged that kitchen staff, including himself, were expected to monitor use-by dates and dispose of expired items, and stated that residents are at risk of foodborne illnesses if they receive expired food items. This deficient practice was determined to have the potential to affect all 46 residents listed on the facility’s census at the time of the survey.
Failure to Follow Transfer Requirements and Fall-Prevention Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and appropriate fall prevention measures for two residents. One resident with dementia and Alzheimer’s disease, who was dependent on staff for most ADLs, was care planned and documented in the Kardex as requiring a one-person stand-and-pivot transfer with a gait belt. There was no documentation in the EMR indicating a need for a Sara lift or any other mechanical transfer device. Despite this, a CNA used a Sara lift to transfer the resident from bed to wheelchair, during which the resident experienced a witnessed fall, sustaining a head injury and a skin tear to the left wrist and requiring transfer to the ER. The DON confirmed that the fall occurred because the CNA used a Sara lift even though the resident did not require one, and both the CNA and DON stated that staff are expected to be familiar with each resident’s transfer requirements. The second resident, with aphasia, dementia, and Alzheimer’s disease, had a documented history of nine falls, including falls from bed and wheelchair related to leaning forward, confusion, balance problems, poor communication/comprehension, and unawareness of safety needs. The resident’s care plan included interventions such as placing a fall mat on both sides of the bed when the resident was in bed. However, review of the EHR showed that required fall risk assessments had not been completed since September 2024, despite the facility’s expectation that such assessments be done on admission, quarterly, and after each fall. During an observation, the resident was found lying in bed without the fall mat in place as care planned; instead, the mat was stored against the wall. The DON confirmed that the fall risk assessments were not completed as required and that the fall mat should have been present whenever the resident was in bed.
Failure to Safeguard Resident PHI on Medication Cart and Census Documents
Penalty
Summary
Surveyors identified a deficiency related to failure to safeguard residents' protected health information (PHI) on the 600-unit. During an observation of the unit medication cart located by the fireplace in the common room, a white piece of paper containing PHI, including resident names and vital signs, was left unattended and visible to anyone nearby. An LPN confirmed that the paper contained PHI and had been left visible on the cart. In a separate observation, the 600-unit medication cart was left unattended outside a resident room with PHI displayed on the computer screen, including full resident names, prescribed medications, and allergies, and an RN confirmed that this information was visible to anyone walking by and that best practice is to ensure PHI is not visible to everyone. Additional observations showed that the daily unit census, containing full resident names and room numbers, was left unattended and visible on the 600-unit medication cart. An LPN confirmed that this PHI was visible to anyone walking by and stated that such information should always be covered to protect resident PHI. In an interview, the DON stated that the expectation is for PHI to be protected and not open for anyone's ability to view. These observations and staff confirmations demonstrate that PHI for residents on the 600-unit was repeatedly left exposed in common and hallway areas where unauthorized individuals could access it.
Unnecessary Wanderguard Use and Movement Restrictions on Cognitively Intact Resident
Penalty
Summary
The deficiency involves the use of a Wanderguard (elopement-prevention device) on a cognitively intact resident without adequate assessment, documentation, or evidence of unsafe wandering or elopement behaviors. Facility policies on elopement and wandering management state that elopement applies to residents with impaired cognition and/or poor safety awareness, and that residents will be assessed for elopement risk upon admission and at set intervals. The Wanderguard policy specifies that restraining an ambulatory resident simply to prevent wandering is unacceptable and that residents should feel allowed their freedom while under close observation. Despite these policies, the resident was placed on a Wanderguard, and the Medical Safety Device Assessment used for Wanderguard placement was documented as incomplete. The resident’s records showed an admission date with diagnoses including Type 1 diabetes mellitus, anxiety disorder, major depressive disorder, and an initial diagnosis of dementia that was later questioned. A speech therapy discharge summary documented a MOCA score of 28/30, indicating no severe cognitive impairment, and prior cognitive functioning without need for supervision. A neuropsychological evaluation reported that dementia screening was negative, and the facility’s medical director agreed with a diagnosis of neurocognitive disorder but disagreed with the dementia diagnosis. The admission MDS documented a BIMS score of 15, indicating intact cognition, and no wandering behaviors exhibited. The resident’s care plan, however, labeled the resident as an elopement risk/wanderer related to a history of attempts to leave the facility unattended, called for monitoring location every 15 minutes, and documented use of a security bracelet related to poor safety awareness and forgetfulness associated with Type 1 diabetes, but did not include documented evidence of unsafe wandering or elopement attempts. The resident repeatedly reported psychosocial distress related to the Wanderguard and movement restrictions. In complaint intake forms, the resident stated that the Wanderguard prevented leaving the unit to attend activities elsewhere on campus, caused feelings of isolation among residents with cognitive deficits, and contributed to depression and negative effects on mental health. The resident reported feeling like a “chained elephant in a cage” and expressed a desire for more rights and the ability to do enjoyable activities, including worship and socializing in the independent living area where the resident had previously lived. Staff interviews confirmed the resident’s emotional distress: the SSD and NP reported the resident cried, shook, and became upset about loss of independence and Wanderguard use, and an LPN stated the resident felt she was losing independence due to the device. Facility staff provided varying accounts regarding the rationale for the Wanderguard. The DON stated the resident was assessed as a moderate elopement risk and that the Wanderguard was placed after this assessment, citing concerns about diabetic management, missed insulin doses, and inconsistent blood sugar monitoring, including an episode of blood sugar at 400 when the resident left without appropriate checks. The MD stated the Wanderguard was applied after two less restrictive safety measures failed, describing periods of clarity followed by behavioral escalation, removal of the device, attempts to leave to see the resident’s husband and dog, and aggressive behaviors, and characterized some unsupervised departures as elopement. However, the SSD stated she was unaware of any elopement attempts and confirmed the resident’s BIMS score of 15 with no cognitive concerns. The spouse reported that the resident was capable of independent activities in the area, believed the resident could leave the main building if staff were informed, and stated that after the resident left to attend to her dog and returned, the Wanderguard was placed. Despite the resident’s intact cognition and incomplete documentation of elopement risk and less restrictive interventions, the Wanderguard and associated movement restrictions remained in place, limiting the resident’s freedom of movement and contributing to psychosocial distress.
Failure to Complete Significant Change MDS Assessments for Residents Starting Hospice
Penalty
Summary
The facility failed to complete required significant change in condition MDS assessments when two residents began receiving hospice services. One resident with diagnoses including aphasia, dysphagia, dementia, Alzheimer’s disease, and pulmonary embolism was referred to hospice for dementia on 11/17/25, with nursing progress notes documenting the start of hospice services on 11/18/25. However, the resident’s quarterly MDS dated 12/02/25 indicated the resident was not receiving hospice services, despite hospice having already begun. Another resident with diagnoses including aphasia, dysphagia, dementia, heart disease, NSTEMI myocardial infarction, peripheral vascular disease, and hyperlipidemia was referred to hospice for a heart disease–related diagnosis on 08/25/25, with hospice admission records showing hospice services began the same day. Review of this resident’s MDS assessments showed that a significant change in condition MDS was not completed after hospice services were initiated. During an interview, the MDS Coordinator stated that a significant change in condition MDS should always be completed when a resident begins hospice services and confirmed that such assessments were not completed for these two residents.
Failure to Secure Medication Carts and Remove Expired Supplies
Penalty
Summary
Surveyors identified a deficiency related to the storage and security of medications and medical supplies on the 600 unit. During an observation on the unit, a medication cart was found unlocked and unattended outside a resident room, and the responsible RN acknowledged that he had left the cart in that condition, stating that medication carts should not be left unlocked and unattended. In a separate observation of the 600-unit medication storage room, surveyors found expired Universal Viral Transport testing swabs for Chlamydia, Mycoplasmas, and Ureaplasma in a drawer, with an expiration date of 05/14/25. The RN present confirmed the expiration date and stated that expired medical supplies and equipment should be discarded per policy. Further observations of the 600-unit medication cart revealed an oval light blue pill stamped with "SG" that was loose in a drawer, and the same RN confirmed the presence of the loose pill and stated that medication carts should be free of loose medications. In another observation of a common area, a medication cart was again found unlocked and unattended, containing residents' scheduled oral medications, eye drops, inhalers, and injectable medications. The LPN responsible for that cart confirmed it was her cart and stated that her expectation was to lock the cart when unattended, acknowledging that ingestion of non-prescribed medication by a resident could cause a bad drug interaction and illness. The DON later stated that medication carts should always be locked when nurses are away, kept clean and free of loose medications, and that there should be no expired supplies in medication rooms or carts.
Inaccurate Care Plan for Resident on Antiplatelet Therapy
Penalty
Summary
Facility staff failed to develop an accurate, comprehensive, person-centered care plan for one resident related to the resident’s medication regimen. The resident was admitted with multiple cardiovascular diagnoses, including coronary artery disease, paroxysmal atrial fibrillation, congestive heart failure, and peripheral vascular disease. Physician orders dated 12/16/25 showed the resident was prescribed Clopidogrel Bisulfate 75 mg by mouth in the morning for coronary artery disease, which is an antiplatelet medication. The resident’s MDS dated 05/27/25 documented that the resident was taking an antiplatelet medication and not an anticoagulant. Despite this, the resident’s care plan dated 05/28/25 stated the resident was on anticoagulant medication therapy and at risk from taking blood-thinning medications, inaccurately reflecting the type of medication actually prescribed and administered. During observation and interview on 12/15/25, the resident was noted to have bruising on both hands and reported being on an anticoagulant and bruising easily. In a subsequent interview on 12/19/25, the DON confirmed that the electronic medical record did not show an anticoagulant order, acknowledged that the resident had been care planned for an anticoagulant instead of an antiplatelet, and stated that anticoagulants and antiplatelets are significantly different types of medications.
Failure to Obtain Hospice Order and Follow Diabetic Medication Orders
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident receiving hospice services. One resident with diagnoses including aphasia, dysphagia, dementia, Alzheimer’s disease, and pulmonary embolism was admitted to the facility and later had a physician order dated 11/17/25 to be referred to hospice for dementia. Nursing progress notes documented that hospice services began on 11/18/25, and the resident’s care plan initiated on 11/11/25 indicated the resident was admitted to hospice for a terminal prognosis and multiple comorbidities. However, the quarterly MDS dated 11/20/25 indicated the resident was not receiving hospice services, and there was no active physician order for hospice care in the record, which the DON confirmed should have been present for any resident admitted under hospice care. The facility also failed to follow physician orders for a resident with Type 2 Diabetes Mellitus. The resident’s comprehensive care plan dated 10/21/24 documented an intervention to increase Metformin from 500 mg to 1,000 mg daily, and a physician order dated 12/16/25 specified Metformin 1,000 mg. During an observation on 12/17/25, an RN administered only one 500 mg tablet of Metformin instead of the ordered 1,000 mg dose. In a subsequent interview, the RN acknowledged not following the physician’s order when administering the medication, and the DON confirmed that nursing staff are expected to follow physician orders and administer the correct medication dose.
Failure to Follow Physician Orders for Monthly Weights and Monitor Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident by not following physician orders for monthly weights. The resident, who had multiple sclerosis and was admitted with this diagnosis, had a quarterly MDS dated 12/08/25 that lacked a documented weight, despite instructions to base the weight on the most recent measure in the last 30 days. Physician orders included a regular texture, thin liquid diet, an order dated 02/04/25 to weigh the resident every month for routine monitoring, and an order dated 08/26/25 for Prostat nutritional supplement twice daily for wound healing. The resident’s care plan, dated 08/26/25, identified potential nutrition risk due to inadequate oral intake, non-significant weight loss, and increased nutrition needs related to wound care, with interventions that included weighing per physician orders. Review of the electronic health record weight tracking from 03/01/25 through 12/22/25 showed documented weights on 03/25/25 and 04/01/25 of 125.4 lbs and on 07/01/25 of 120.8 lbs, with no documented weights after 07/01/25. A nutritional evaluation dated 10/25/25 documented a 3% weight loss (4.6 lbs) compared to the 04/01/25 weight. During an interview on 12/22/25, the DON confirmed that the last documented weight was in July 2025, acknowledged that the resident should have been weighed monthly per physician orders, and stated that if the resident refused weights, this should have been documented in the EHR. The DON stated the resident’s weights were not being consistently monitored and should have been.
Significant Insulin Dosing Error Due to Duplicate Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. The facility’s own Medication Administration Assistance Policy, dated 04/2017, requires staff to check the medication order for proper route, dose, time, strength, frequency, and type, and to notify the physician immediately of problems with medications. The resident, who had Type I diabetes mellitus with hyperglycemia, long-term insulin use, and unspecified cognitive symptoms, was admitted on a specified date and had physician orders for Insulin Glargine-yfgn 15 units at bedtime for diabetes. Physician orders dated over two consecutive days both directed administration of 15 units of Insulin Glargine-yfgn at bedtime, creating duplicate orders for the same long-acting insulin. Record review of the Medication Error Incident Report showed that the resident received the wrong dose of insulin when 17 units of long-acting insulin were administered instead of the ordered 15 units. The incorrect order and dosing error were not identified by the physician until several days later, during which time the resident experienced low blood sugars for multiple days after the additional administration. The Medication Administration Record confirmed that both insulin orders remained active until they were discontinued on the same later date. During an interview, the DON acknowledged that a medication error occurred and that the resident received a duplicate insulin order for several days and should not have, and stated that her expectation is that all residents receive correct medications and dosages per physician orders.
Failure to Sanitize Blood Pressure Equipment for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe, sanitary environment to prevent transmission of infectious agents when a nurse did not clean and sanitize vital sign equipment after use on a resident under Enhanced Barrier Precautions. During observation on 12/18/25 at 8:24 AM, an LPN took blood pressure measurements for Resident #39, who was on Enhanced Barrier Precautions, and then failed to sanitize the blood pressure cuffs before leaving the resident’s room. The LPN then proceeded to document medication administration on a facility computer located on top of the medication cart without having disinfected the equipment used on the resident. In a subsequent interview at 8:25 AM, the LPN confirmed that she forgot to clean the blood pressure cuffs after using them on Resident #39 and acknowledged that, per facility policy, the cuffs should have been cleaned prior to leaving the resident’s room. The LPN also confirmed that Resident #39 was on Enhanced Barrier Precautions at the time of the incident. The survey findings state that this deficient practice is likely to result in the transmission of infectious agents between residents and staff.
Failure to Protect Resident from Exploitation and Misappropriation of Property
Penalty
Summary
A facility failed to protect a resident from exploitation and misappropriation of property by a sales consultant employed at a sister facility within the same corporate campus. The sales consultant, who had access to the resident's personal and financial information through the Independent Living facility's intake process, fraudulently obtained a $1,569 refund for the resident's hearing aids after her death by misrepresenting himself as her grandson to an outside company. The refund was deposited into his personal account rather than the resident's estate. The sales consultant did not notify facility administration or seek direction regarding the handling of the resident's property, and only later sent a cashier's check to the resident's Power of Attorney for Finance, which was made out incorrectly. The resident in question had severe cognitive impairment, as evidenced by a BIMS score of 00 and diagnoses including metabolic encephalopathy, altered mental status, and dementia. She was admitted to the Skilled Nursing facility after a period in the Independent Living facility, and her medical records indicated ongoing confusion and vulnerability. The resident's Power of Attorney for Finance was not informed about the sale of the resident's house, which was purchased by the same sales consultant for less than market value, with significant closing fees deducted. The Power of Attorney expressed concerns that the resident was isolated from trusted advisors and did not fully understand the transactions she was involved in. Facility staff and visitors were able to move freely between the three facilities on campus without signing in, and there was no visitor log to track who entered or visited residents. Multiple staff members, including a social worker and an anonymous staff member, were aware of irregularities regarding the sales consultant's involvement with the resident's affairs but did not consistently report these concerns to administration or authorities. The Executive Director acknowledged awareness of the home purchase but did not provide investigation records, and the facility did not provide relevant records from the resident's time in the Independent Living facility, stating they were not relevant to her stay in the Skilled Nursing facility.
Improper Food Storage and Expired Items in Kitchen
Penalty
Summary
The facility failed to store and serve food under sanitary conditions, as observed during an inspection of the kitchen. Raw salmon was improperly stored in a zip-lock bag above small cups of salsa in the refrigerator, which could lead to cross-contamination. The Director of Dining Services acknowledged that this was against the facility's food storage protocols, which require staff to ensure food is stored correctly to prevent contamination. Additionally, during an observation of the dry storage area, four unopened and expired bottles of salad dressings were found mixed with unexpired ones, and a bottle of liquid smoke was discovered with a broken seal and without a lid. Kitchen Staff #1 confirmed that expired items should not be present in the storage area and should be discarded. The Director of Dining Services stated that staff are expected to check the dry storage area every two days to remove expired items and ensure all items are adequately sealed and labeled.
Infection Control Breach: Oxygen Cannula Dragging on Floor
Penalty
Summary
The facility failed to maintain proper infection prevention measures when a resident's oxygen nasal cannula dragged on the hallway floor. The resident, who had a physician's order for continuous oxygen therapy due to hypoxia, was observed propelling herself in a wheelchair toward an activity while her nasal cannula and oxygen line trailed behind her on the floor. During an interview, the resident expressed her discomfort upon realizing that the cannula she used in her nose had been in contact with the floor. The facility's Infection Preventionist Registered Nurse confirmed that oxygen tubing and nasal cannulas should not drag on the floor due to the risk of contamination from bacteria, viruses, and germs.
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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