The Neighborhood In Rio Rancho
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Rancho, New Mexico.
- Location
- 900 Loma Colorado Blvd Ne, Rio Rancho, New Mexico 87124
- CMS Provider Number
- 325130
- Inspections on file
- 25
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at The Neighborhood In Rio Rancho during CMS and state inspections, most recent first.
The facility failed to protect a resident from exposure to physical and mental abuse when a CNA and an RN engaged in a verbal and physical altercation in the resident’s room and on the resident’s bed while the resident was present. The resident, who had multiple serious conditions including a right femur fracture, COPD, DM2, HTN, pulmonary embolism with acute cor pulmonale, generalized muscle weakness, and a cognitive communication deficit, was awakened by noise and movement of the bed as the struggle occurred. Police and staff accounts indicated that the confrontation escalated from the hallway into the room, with the CNA and RN physically fighting next to and on the bed, and furniture in the room being moved. The resident later reported to a psychiatrist that she witnessed the altercation, felt frightened, anxious, and depressed, and stated she did not feel safe.
A CNA failed to prevent abuse of a dependent resident with multiple medical conditions by handling her forcefully and aggressively during care, contrary to the care plan requiring two-person assistance. The incident was captured on video, showing the resident appearing scared and confused, and was reported by the family. The CNA did not request help from available staff and later admitted to using excessive force.
Two residents experienced deficiencies in care when necessary fall assessments and interventions were not completed after a fall, and when a Hoyer lift transfer was performed by only one staff member instead of the required two. One resident with multiple medical conditions did not receive post-fall assessments or care plan updates, while another dependent resident was transferred alone despite orders for two-person assistance. The DON confirmed that standard procedures were not followed in both cases.
A resident with dementia and dysphagia did not have accurate or consistent weights recorded as ordered, with missed and incorrect entries not followed by timely re-weighs. Staff interviews confirmed ongoing problems with obtaining weights and reliable meal intake documentation. These failures led to a delay in identifying significant weight loss and in starting a nutritional supplement.
The facility did not ensure accurate and complete medical records for two residents, including inconsistent documentation of physical abilities, lack of fall assessments and care plan updates after a fall, missing ADL entries for multiple days and shifts, incomplete shower records for a hospice resident, and inaccurate meal intake documentation. Staff interviews confirmed that CNAs sometimes documented for residents they did not care for, and required documentation was not consistently completed as expected.
A resident with multiple chronic conditions experienced a decline and a change in diet after returning from the hospital. Although the legal guardian was listed as the primary contact, staff failed to notify the guardian of these changes, with documentation and interviews confirming the lack of communication. Instead, a different family member was contacted, and the guardian remained unaware of the resident's updated condition and care needs.
The facility did not provide orientation or verify competencies for agency CNAs and RNs before they began working, relying solely on the contracting agency for training and background checks. This led to incidents where a CNA was unaware of a resident's need for assistance with dressing, causing distress, and an RN sent a hospice patient to the hospital without knowledge of their hospice status. Staff interviews and record reviews confirmed the absence of facility-led orientation and incomplete training records for agency staff.
Two residents receiving hospice care were improperly billed by the facility for items and services such as oxygen equipment, medications, wipes, and adult briefs, which should have been covered by hospice. The billing specialist confirmed these charges were made while waiting for clarification on hospice-covered items.
A resident with severe cognitive impairment developed new wounds, and the POA was not notified of these injuries. The POA discovered the injuries during a visit and was unable to obtain information from staff or records about the cause. The DON confirmed that notification did not occur as required.
The facility did not update care plans for three residents after significant changes in their care needs, including a fall resulting in a hip fracture and the initiation of hospice services. Despite documentation and confirmation from the DON, care plans were not revised to include new interventions or reflect hospice care, leaving important changes in condition unaddressed.
Two residents did not have proper documentation or coordination of hospice services, including missing hospice orders, lack of qualifying diagnoses, and absent hospice plans of care. In one case, staff failed to notify the hospice agency of a significant change in condition, and in both cases, the Director of Nursing confirmed that required hospice documentation and care planning were not in place.
A resident with multiple diagnoses, including vascular dementia and behavioral disturbances, was involved in an incident where staff observed aggressive behavior. However, the annual MDS assessment did not document any behavioral symptoms, and the MDS Coordinator confirmed the assessment was inaccurate.
A resident with multiple medical conditions, requiring assistance for transfers, fell and was injured when a Hoyer lift sling broke during a transfer. Only one CNA was present, despite the requirement for two staff members. The facility acknowledged negligence in not following proper procedures.
A resident with multiple health conditions, including muscle weakness and reduced mobility, fell and sustained injuries when a Hoyer sling broke during a transfer. The facility's maintenance policy required regular equipment inspections, but the Administrator confirmed that maintenance staff had not checked the sling prior to the incident, contributing to the equipment failure.
The facility failed to store food in accordance with professional standards when staff stored expired food in the walk-in refrigerator. During an observation, three packages of tofu with an expiration date were found in the refrigerator. The chef acknowledged that expired tofu should be discarded, and the Director of Dining Services confirmed that kitchen staff should check the refrigerator daily for expired foods and discard them when found.
A facility failed to provide prescribed wound care for a resident with malignant melanoma and a surgical removal of the right breast. The resident's MAR indicated daily wound care, but staff completed the treatment only two out of ten times. Interviews revealed inconsistencies and a lack of clarity regarding wound care responsibilities, leading to the resident not receiving appropriate and timely care.
The facility failed to ensure proper handling and storage of medications and medical supplies. Loose medications were found in a medication cart, expired supplies were stored with unexpired ones, and fentanyl patches were improperly stored in the medication cart instead of being destroyed immediately.
The facility failed to update the care plan for a resident who was admitted to hospice services. The resident's EMR indicated hospice services began in January, but a review in April showed the care plan lacked this information. The Social Services Director confirmed the care plan should have been updated but was not.
The facility failed to notify the Pharmacist and DON about a morphine spill and a missing fentanyl patch for two residents, leading to improper handling and documentation of medications.
A resident with a history of pneumonia was found with oxygen tubing that had not been changed for over a month. The physician's orders lacked specific instructions on tubing replacement frequency, and a nurse confirmed it should be changed weekly but was not.
A resident fell in the dining room while playing Bingo, and although family members were present, the facility failed to notify the POA and NP. The DON confirmed that staff should always inform the POA of any falls, and the NP confirmed she was not made aware of the incident.
A resident with Parkinson's disease receiving hospice care was incorrectly administered morphine sulfate as a scheduled medication instead of PRN due to a transcription error by an agency nurse. The resident received multiple doses before the mistake was identified and corrected, causing distress to the resident's daughter.
The facility failed to provide necessary behavioral health treatment for a resident diagnosed with dementia and schizophrenia, who exhibited insomnia and aggressive behavior. Despite frequent monitoring and documentation of the resident's agitation and restlessness, no physician orders or behavioral health consults were initiated to address these issues. Interviews with staff revealed awareness of the resident's problems, but no actions were taken to provide appropriate care.
The facility failed to monitor the behaviors of a resident on psychotropic medications, despite documented aggressive and restless behaviors. The Treatment Administration Record lacked sufficient documentation, and staff interviews confirmed the resident's frequent noncompliance and falls. This represents a significant deficiency in care practices.
The facility failed to ensure resident furniture was in operable condition, as evidenced by the continued use of a broken recliner. An observation revealed a recliner with a footrest that did not lock in the elevated position. The DON confirmed that staff had been using a foot stool to keep the footrest elevated and acknowledged that the broken recliner should not have been available for resident use.
Failure to Protect Resident From Staff Altercation in Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment free from abuse when a physical and verbal altercation between two staff members occurred in a resident’s room and on the resident’s bed while the resident was present. The resident had been admitted with multiple serious medical conditions, including a displaced fracture of the right femur, COPD, DM2, HTN, pulmonary embolism with acute cor pulmonale, generalized muscle weakness, and a cognitive communication deficit. An MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. Despite these vulnerabilities, the facility did not prevent staff from engaging in a violent confrontation in the resident’s immediate care environment. According to a police report, a CNA stated that an RN pushed him, and he pushed the RN into a resident room, where he punched her in the face and then restrained her on the ground. The RN reported that she had prior issues with the CNA and that on the night of the incident she observed him yelling in a patient’s room while on the phone with the DON. She stated that after she told him to leave the facility to take the call elsewhere, he approached and punched her multiple times in the face, dragged her by the collar into the resident’s room, and continued the assault on the floor next to the resident’s bed, including placing his knee against her chin and neck. The CNA, in his own account, acknowledged that the physical struggle moved into the resident’s room, that the RN climbed onto the resident’s bed while the resident was still in it and kicked at him, and that a bedside table with a water pitcher was pushed toward him during the altercation. The resident’s psychiatrist reported that the resident described being in bed when she was awakened by noise and feeling her bed move, and that she witnessed the two staff members engaging in a verbal and physical altercation. The psychiatrist stated the resident reported feeling frightened, depressed, anxious, and that she did not feel safe in the facility. The DON later learned that furniture in the resident’s room had been moved during the incident and that the resident was found wrapped in a blanket and being consoled by CNAs. The DON reported that the resident was very anxious and stated she heard loud voices and felt her bed being bumped. These events demonstrate that the facility failed to protect the resident from exposure to physical and mental abuse by not preventing or adequately controlling a staff-on-staff altercation that occurred in the resident’s room and on her bed while she was present.
Failure to Prevent Staff-to-Resident Abuse During Dependent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to prevent abuse of a resident who was dependent on staff for all activities of daily living. The resident had significant medical conditions, including cerebral infarction, type II diabetes, vascular dementia, Parkinson's disease, and dysphagia, and was on hospice care. The resident was unable to complete a cognitive assessment due to impairment and required the use of a Hoyer lift with two-person assistance for transfers, as documented in her care plan. On the evening of the incident, video evidence showed the CNA forcefully and aggressively handling the resident during a brief change and repositioning, including grabbing, pulling, and pushing the resident in a manner that appeared angry and intimidating. The CNA performed these actions alone, despite the care plan requiring two-person assistance with the Hoyer lift. The resident appeared scared and confused during the incident, as observed in the video. The CNA later admitted to using excessive force and acknowledged that the resident was fully dependent on staff for care. Interviews with staff and review of records indicated that the CNA did not request help from another CNA, who was available and routinely assisted with Hoyer transfers. The CNA stated she was not angry but found it difficult to work with the resident due to her lack of mobility. The incident was reported by the resident's family, who observed the abuse via a video camera in the room. The CNA had no prior disciplinary issues, and other staff reported no previous concerns about her conduct. The incident was confirmed through video review and staff interviews.
Failure to Complete Fall Assessments and Ensure Proper Hoyer Lift Use
Penalty
Summary
The facility failed to complete necessary assessments, open a risk management report, create interventions for a fall, and use two staff when operating a Hoyer lift for two residents reviewed for falls. In the first case, a resident with dementia, dysphagia, frontal lobe deficit, hypertension, and a cardiac pacemaker experienced a fall. The resident was found on the floor next to her bed, was awake and alert, and had no obvious injury. Despite this incident, there was no fall assessment, no neurological checks, no change in condition assessment, no post-fall assessment, and no interventions documented for the fall. The care plan did not include any focus or intervention for the fall until a month later, after a second fall occurred. The resident's son confirmed that no interventions were implemented following the initial fall, and staff interviews revealed that standard procedures for post-fall assessment and intervention were not followed in this instance. In the second case, a resident with cerebral infarction, type II diabetes, vascular dementia, Parkinson's disease, and dysphagia was dependent on staff for all activities of daily living and required the use of a Hoyer lift with two-person assistance for transfers. The care plan and physician orders specified that two staff members were required for all Hoyer lift transfers. However, a CNA admitted to transferring the resident alone using the Hoyer lift because her coworker was busy with other residents. Other staff confirmed that the resident required two-person assistance for all transfers and that the proper procedure was not followed during this incident. Interviews with the Director of Nursing confirmed that the required assessments and interventions were not completed for the first resident's fall and that the second resident was transferred using the Hoyer lift by only one staff member, contrary to care plan and physician orders. These failures represent deficiencies in ensuring the area was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.
Failure to Obtain Accurate Weights Delays Nutritional Intervention
Penalty
Summary
The facility failed to obtain accurate and consistent weights for a resident with dementia, dysphagia, and a history of cerebral infarction, as required by physician orders. The resident was to be weighed on admission, then weekly for four weeks, and subsequently every Thursday for routine monitoring. However, the weight log showed missing and inaccurate entries, including a documented error that was not followed by a re-weigh, and a missed weight on a scheduled date. There was also no physician order for a re-weigh after an inaccurate weight was recorded. These inconsistencies in weight documentation led to a delay in identifying significant weight loss. Interviews with facility staff, including the Nutritional Services Director, Assistant Director of Nursing, Director of Nursing, and Registered Dietician, confirmed ongoing issues with obtaining timely and accurate weights, as well as challenges in getting re-weighs completed. The resident was noted to have refused meals and required assistance with eating, but meal intake documentation was found to be unreliable. The delay in obtaining accurate weights contributed to a delay in providing a nutritional supplement, which was only ordered after a significant weight loss was finally documented.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three residents reviewed, resulting in multiple documentation deficiencies. For one resident with diagnoses including dementia, dysphagia, and frontal lobe deficit, the history and physical documented independent movement of all extremities, while the Minimum Data Set indicated upper and lower extremity impairment on one side and a need for full assistance with daily activities. Additionally, after this resident experienced a fall, there was no fall assessment, neuro checks, change in condition documentation, post-fall assessment, or care plan interventions related to the incident, despite the resident's family being notified of the fall. Further review revealed significant gaps in the Activities of Daily Living (ADL) documentation for this resident, with multiple days and shifts lacking any entries for essential care tasks such as eating, dressing, and hygiene. For another resident who was on hospice care, the ADL task list showed only sporadic documentation of showers, despite hospice being responsible for providing them on specific days. Meal intake documentation was also found to be inaccurate, with discrepancies between what was charted and what was reported by the CNA who actually assisted the resident. Interviews with staff confirmed that CNAs were sometimes documenting care for residents they did not personally assist, and that required documentation was not consistently completed before the end of each shift. Both the DON and ADON acknowledged these documentation lapses, noting that the ADL task list should be fully completed daily and that only the CNA providing care should document for the resident.
Failure to Notify Guardian of Resident's Change in Condition and Diet
Penalty
Summary
The facility failed to notify the legal guardian of a resident regarding significant changes in the resident's condition and dietary requirements. The resident, who had multiple diagnoses including osteoarthritis, bipolar disorder, type II diabetes, atherosclerosis, and dementia, experienced a decline in condition and a change in diet following a hospital stay. The guardian was listed as the primary emergency contact and responsible party in the resident's records, with contact information clearly documented. Despite this, there was no documentation in the electronic medical record indicating that the guardian was informed of the resident's decline or the change to a puree diet. Interviews with facility staff, including the DON and Social Services Director, revealed that the guardian was not notified of these changes and that staff were unclear about the notification process. The DON stated that the nurse involved did not know who the guardian was and instead notified the resident's grandson. The guardian confirmed during an interview that he was not made aware of the resident's change in condition or diet, and expressed concern about the lack of communication regarding these significant changes.
Failure to Ensure Competency and Orientation of Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that agency nursing staff, including CNAs and RNs, were competent and properly oriented to provide care to residents. Record reviews and staff interviews revealed that agency staff did not receive any training or orientation from the facility prior to starting their shifts. The facility relied on the contracting agency to complete all required verifications and trainings, and did not maintain records of staff training or background checks for agency staff. Multiple staff members, including the administrator, scheduler, and HR, confirmed that no orientation or training was provided to agency staff before they began working with residents. This lack of orientation and competency verification led to specific incidents affecting residents. One resident, with a history of hemiplegia, atherosclerotic heart disease, altered mental status, and other conditions, required substantial assistance with activities of daily living due to left-sided weakness. An agency CNA was unaware of the resident's limitations and instructed the resident to dress herself, resulting in the resident becoming distressed and attempting to strike the CNA. The CNA later admitted to not knowing the resident was unable to dress herself, and her training records showed multiple expired or incomplete trainings, including those related to abuse, dementia care, and essential clinical assessments. Another resident, with diagnoses including heart disease, chronic atrial fibrillation, congestive heart failure, chronic kidney disease, and diabetes, was admitted to hospice care. An agency RN, unaware of the resident's hospice status, sent the resident to the hospital after an episode of aggression and confusion. The administrator confirmed that the nurse was not aware of the hospice status and should not have sent the resident out, further highlighting the lack of orientation and communication regarding residents' care needs.
Improper Billing of Residents for Hospice-Covered Items and Services
Penalty
Summary
The facility failed to prevent charges against residents' personal funds for items and services that should have been covered by hospice, Medicare, or Medicaid. For one resident, after being admitted to hospice, the facility continued to bill the resident for an oxygen concentrator, cannulas, humidifiers, and medications, all of which were related to the resident's terminal diagnosis and confirmed by the hospice agency to be covered under hospice care. The billing specialist acknowledged charging the resident for these items and stated she was waiting for a list of hospice-covered items. Similarly, another resident who was admitted to hospice was billed by the facility for wipes, adult briefs, and a medication, despite these items being potentially covered by hospice. The billing specialist also confirmed these charges and indicated she was awaiting clarification on hospice coverage. These actions resulted in improper charges to residents' personal funds for items and services that should have been billed to the hospice agency.
Failure to Notify POA of Resident Injuries
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for a resident with severe cognitive impairment when injuries or incidents occurred. The resident, who had diagnoses including chronic heart failure, anxiety disorder, insomnia, and adjustment disorder with depressed mood, was found by her POA to have a bandage on her wrist extending to her elbow and a bandaid on her face during a visit. The POA reported not being informed of any new injuries and was unable to obtain information from staff regarding the cause of the injuries. Documentation in the electronic health record indicated a change of condition form listing a skin wound or ulcer, but no cause was provided, and a total body skin assessment revealed two new wounds. Interview with the Director of Nursing confirmed that the POA was not notified of the injuries, despite facility policy requiring notification of POAs when residents are injured. The POA expressed that communication from the facility had declined since a change in management, and staff were unable to provide details about the incident or the injuries. The deficiency was identified through record review and interviews, establishing that the facility did not fulfill its obligation to inform the POA of significant changes in the resident's condition.
Failure to Update Care Plans for Falls and Hospice Services
Penalty
Summary
The facility failed to ensure that care plans were revised and updated for three out of four residents reviewed, specifically in relation to significant changes in their care needs such as falls resulting in injury and the initiation of hospice care. For one resident, after experiencing a fall that resulted in a hip fracture and subsequent hospitalization, the care plan was not updated to reflect the incident or to add new interventions or a fall protocol. The Director of Nursing confirmed that the care plan should have been revised to include these changes but was not. For two other residents, both of whom were admitted to hospice care, the facility did not update their care plans to reflect their new hospice status or to include appropriate interventions for hospice care. Documentation showed that hospice services had begun, and this was confirmed by both the residents' records and the DON, yet the care plans remained unchanged and did not address the residents' current needs related to hospice care. The DON acknowledged that the care plans did not meet expectations for reflecting these significant changes.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services were provided in accordance with professional standards for two out of three residents reviewed. For one resident, there was no documented order for hospice services, and for another, the qualifying diagnosis for hospice care was not clearly established. Additionally, neither resident had a hospice plan of care available in their electronic health records, and the facility did not communicate with the hospice agency regarding a significant change in condition for one of the residents. One resident was admitted to hospice care with an unspecified illness as the diagnosis, and later with COVID as the qualifying diagnosis, which the Director of Nursing (DON) stated did not meet expectations for hospice eligibility. The hospice plan of care was missing from the resident's record, and the care plan was not updated to reflect hospice services when they began. Furthermore, a registered nurse was unaware that the resident was on hospice when the resident was sent to the emergency room, and the hospice agency was not notified of the change in condition until informed by the family. For the second resident, the electronic health record indicated that routine hospice care was to start, but there was no hospice plan of care or order for hospice services documented. The DON confirmed that the resident's record did not contain any information regarding hospice, including a pertinent diagnosis, a coordinated care plan, or inclusion in the agency's care plan. These findings demonstrate a lack of coordination and documentation necessary for the provision of hospice services as required by facility policy and hospice agreements.
Failure to Accurately Assess Resident Behaviors in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident with multiple complex diagnoses, including hemiplegia, atherosclerotic heart disease, altered mental status, major depressive disorder, and vascular dementia. The resident was readmitted after a hospital stay and had a documented history of behavioral disturbances. On review of records, it was found that a police report documented an incident where staff heard a loud scream and observed the resident going after another staff member, indicating behavioral symptoms. Despite this incident, the resident's annual Minimum Data Set (MDS) assessment did not reflect any physical or verbal behavioral symptoms directed towards others. During an interview, the MDS Coordinator confirmed that any changes in behavior should have been reported to her and acknowledged that the annual MDS assessment should have included information on the resident's behaviors, confirming the assessment was not accurate.
Failure to Ensure Proper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was dependent on staff assistance for transfers due to multiple medical conditions, including acute kidney failure, inclusion body myositis, permanent atrial fibrillation, generalized muscle weakness, and reduced mobility. The resident, who was cognitively intact, required the assistance of two or more staff members for transfer activities. However, during a transfer using a Hoyer lift, the sling broke, resulting in the resident falling and sustaining injuries that required hospital treatment. The incident was witnessed, and the resident suffered a skin tear and bruising from the fall. The facility's initial incident report and follow-up documentation revealed that only one CNA was operating the Hoyer lift at the time of the incident, contrary to the requirement for two staff members to assist with such transfers. The administrator confirmed that the sling was not visibly worn, but acknowledged that the proper procedure of having two staff members present was not followed. The facility's follow-up report concluded that there was negligence involved in the incident, as the CNAs did not adhere to the protocol for using the mechanical lift.
Failure to Maintain Safe Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that patient care equipment was in safe operating condition, which resulted in a Hoyer sling breaking and causing a resident to fall and sustain injuries. The resident, who was admitted with multiple diagnoses including acute kidney failure, inclusion body myositis, permanent atrial fibrillation, generalized muscle weakness, and reduced mobility, was dependent on staff assistance for transfers. The incident occurred when the Hoyer sling broke during a transfer, leading to the resident's fall and subsequent transfer to the emergency room for evaluation. The facility's policy required the Maintenance Manager to develop a maintenance schedule and perform regular inspections and testing of equipment. However, the Administrator confirmed that maintenance staff failed to check the condition of the Hoyer sling prior to the incident. Despite the sling not appearing visibly worn at the time of the incident, the lack of documented maintenance checks contributed to the equipment failure. The Administrator was unable to provide information on when the equipment was last inspected, highlighting a lapse in adherence to the facility's maintenance policy.
Expired Food Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards when staff stored expired food in the walk-in refrigerator. During an observation, three packages of tofu with an expiration date were found in the refrigerator. The facility's chef acknowledged that expired tofu should be discarded and not stored. Additionally, the Director of Dining Services confirmed that the kitchen staff should check the refrigerator daily for expired foods and discard them when found. This deficiency had the potential to negatively impact all 47 residents listed on the census provided by the Director of Nursing.
Failure to Provide Prescribed Wound Care
Penalty
Summary
The facility failed to provide quality care by not administering wound care as prescribed for a resident with a history of malignant melanoma and a surgical removal of the right breast. The resident's Medication Administration Record (MAR) indicated that wound care was to be provided daily for a wound on the right breast and every three days for a wound on the front wall of the thorax. However, a review of the MAR from 05/14/24 to 05/23/24 revealed that staff completed the wound care treatment only two out of ten times. Additionally, hospice care notes indicated that hospice provided wound care only once during this period, on 05/14/24, with no further documentation of wound care provided by hospice thereafter. Interviews with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (IDON) revealed inconsistencies and a lack of clarity regarding the responsibility for wound care. The ADON stated that the facility did not have a designated wound care staff and relied on RNs on shift to provide the care. The IDON acknowledged that there were two contradictory orders for wound care, one for daily care and another for care every three days by hospice, and stated that the expectation was for the nurse on the floor, the DON, or the ADON to discontinue one of the orders to avoid confusion. This lack of coordination and adherence to prescribed wound care regimens resulted in the resident not receiving appropriate and timely wound care, potentially leading to discomfort and infection.
Improper Handling and Storage of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure proper handling and storage of medications and medical supplies. During an observation of the 300 hall medication cart, a loose white, circular tablet was found under the medication cards. A Certified Medication Aide confirmed that loose medications should not be present in the cart and that staff should check for loose medications at the beginning of each shift. Additionally, expired medical supplies, including twenty IV start kits and one hundred safety needles, were found stored with unexpired supplies in the 300 hall medication storage room. A Licensed Practical Nurse acknowledged that expired supplies should not be stored with unexpired ones and should be removed by staff and given to the charge nurse or Director of Nursing. The facility also failed to properly handle fentanyl patches. A nurse admitted to placing a removed fentanyl patch in the medication cart until it could be destroyed, citing the unavailability of a second nurse to assist with the destruction. Both the Assistant Director of Nursing and the Director of Nursing confirmed that fentanyl patches should be destroyed immediately upon removal, with two nurses signing and dating a form to document the destruction. They stated that they were always available to assist with this process, and the patches should not be stored in the medication cart.
Failure to Update Care Plan with Hospice Services
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was admitted to hospice services. The resident's Electronic Medical Record (EMR) indicated that hospice services began on January 17, 2024. However, a review of the care plan on April 24, 2024, revealed that it did not include any information about the hospice services. During an interview on May 22, 2024, the facility's Social Services Director confirmed that the care plan should have been updated to reflect the hospice services, but it was not.
Failure to Notify Pharmacist and DON of Medication Issues
Penalty
Summary
The facility failed to meet professional standards of quality when staff did not notify the Pharmacist and the Director of Nursing (DON) about a morphine spill and a missing fentanyl patch for two residents. For the first resident, there was an order for a fentanyl patch to be applied every 72 hours. On one occasion, the nursing staff applied a new patch but could not find the old one. The Assistant Director of Nursing (ADON) and the nurse managers were not aware of this incident, and there was no documentation found regarding the missing patch. The facility's procedure required staff to notify the DON if a patch could not be located, which was not followed in this case. For the second resident, there was an order for morphine concentrate solution to be administered as needed for pain or shortness of breath. The narcotic log sheet indicated that 4 ml of morphine was wasted, but the staff did not notify the Pharmacist or the DON about the spill. The Pharmacist expected to be informed of such incidents and for a new order to be placed, with the old bottle being destroyed. However, the morphine bottle was still found in the medication cart, indicating a failure to follow proper procedures for handling and documenting medication spills.
Failure to Change Oxygen Tubing as Required
Penalty
Summary
The facility failed to meet professional standards of care for a resident requiring respiratory care by not changing the oxygen tubing as needed. The resident, who had a history of pneumonia, was observed with oxygen tubing dated over a month old. The physician's orders did not specify the frequency for changing the tubing, and a nurse confirmed that the tubing should be changed weekly but was not. This oversight could lead to respiratory infections due to dirty or clogged tubing, compromising the resident's oxygen supply.
Failure to Notify POA and NP of Resident's Fall
Penalty
Summary
The facility failed to notify the power of attorney (POA) and the Nurse Practitioner (NP) of a fall experienced by a resident. The resident fell in the dining room while playing Bingo, and although family members were present, the POA and NP were not informed. The Director of Nursing (DON) confirmed that staff should always inform the POA of any falls, even if a family member was present. The NP also confirmed that she was not made aware of the fall, as indicated by the absence of any notes regarding the incident in the resident's medical record.
Failure to Follow Physician's Order for Medication Administration
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with Parkinson's disease who was receiving hospice care. The resident had a PRN order for morphine sulfate to be administered as needed for pain or shortness of breath. However, the order was incorrectly transcribed by an agency nurse as a scheduled medication to be given every four hours. As a result, the resident received morphine at 4:00 pm and 8:00 pm on the first day, and at 12:00 am, 4:00 am, and 8:00 am on the following day, instead of only when needed for pain or shortness of breath. The error was discovered when the resident's daughter called the facility and was informed that her father was resting due to the administration of morphine. The Director of Nursing confirmed that the initial order was for PRN administration, but the agency nurse had entered it incorrectly as a scheduled medication. The resident received three doses of morphine before the mistake was identified and corrected. The nursing notes also indicated that the resident's daughter was extremely upset about the incorrect administration of the medication.
Failure to Provide Behavioral Health Treatment for Resident with Insomnia
Penalty
Summary
The facility failed to provide necessary behavioral health treatment for a resident diagnosed with dementia with agitation and schizophrenia, who was experiencing insomnia. The resident was admitted to the facility and exhibited multiple instances of aggressive and restless behavior, including being combative, verbally abusive, and attempting to self-propel into other residents' rooms. Despite these documented behaviors, the resident did not have any physician orders to address his lack of sleep or nighttime behaviors. Staff frequently monitored the resident and documented his agitation and restlessness, but no behavioral health consult or treatment for insomnia was initiated during his stay at the facility. Interviews with the nursing staff and the Director of Nursing revealed that the resident's insomnia and behavioral issues were known, but no actions were taken to address them. The Nurse Practitioner was unaware of the resident's insomnia issues, and the Director of Nursing confirmed that no referral for a behavioral health consult was made. The resident had previously received behavioral health care at another facility, but this care was not continued at the current facility. This lack of appropriate behavioral health treatment could likely lead to increased agitation, restlessness, and falls for the resident.
Failure to Monitor Resident Behaviors on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident (R #1) who was on psychotropic medications. The resident, diagnosed with dementia with agitation and schizophrenia, exhibited frequent aggressive and restless behaviors, including screaming, kicking, and attempting to get out of bed unassisted. Despite these behaviors being documented in nursing progress notes, the Treatment Administration Record (TAR) did not contain sufficient documentation to indicate that staff monitored these behaviors as required by the physician's orders and care plan. Specifically, the TAR lacked entries for monitoring agitation, yelling, cursing, and combativeness, and staff only documented '0' for behaviors and redirection without further details. The resident's care plan included specific instructions to monitor for side effects of antipsychotic medications and to document any behavioral symptoms every shift. However, the TAR did not reflect consistent monitoring or documentation of the resident's behaviors and responses to medication. Interviews with nursing staff confirmed that the resident was frequently aggressive, restless, and noncompliant, often refusing medications and attempting to leave the unit or get up unassisted, leading to multiple falls. The lack of proper documentation and monitoring of the resident's behaviors and medication side effects represents a significant deficiency in the facility's care practices. This failure to adhere to the care plan and physician's orders could result in the resident continuing to exhibit unaddressed behaviors, potentially leading to further harm or distress for the resident and others in the facility.
Broken Recliner Poses Fall Risk
Penalty
Summary
The facility failed to ensure resident furniture was in operable working condition, as evidenced by the continued use of a broken recliner for one of three residents reviewed for falls. On 03/29/24 at 11:32 am, an observation near the nurse's station revealed a recliner with a footrest that was not attached to the mechanism that extended to raise and support the feet. During interviews on 03/29/24 and 04/02/24, the Director of Nursing (DON) confirmed that the footrest on one of the recliners did not lock when in the elevated position and would fall from the elevated position. Staff had been placing a foot stool under the footrest to keep it elevated while a resident sat in the chair. The DON acknowledged that the broken recliner should not have been available for resident use.
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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