Inspection Reports for Albuquerque Heights Healthcare and Rehabilitation Center

The complaint investigation found that the facility failed to protect residents from accidents and hazards for 1 of 4 residents reviewed for falls by not preventing a resident from falling out of bed. The resident sustained an abrasion and required neurological checks. Staff interviews confirmed the bed was left in a high position and the resident was left on the edge of the bed unattended.

The facility failed to protect residents from accident hazards by not preventing a resident (R #20) from falling out of bed. The resident was left unattended on the edge of the bed in a high position, resulting in a fall and minor injury. Staff interviews confirmed inappropriate practices contributing to the incident.

The facility failed to develop a comprehensive care plan for one resident (R #4) that included necessary interventions for transfer assistance consistent with assessed needs and physician orders, potentially increasing the risk of falls and injuries.

The facility was found to have ongoing issues with insufficient linens, including towels and facecloths, which impacted residents' ability to receive showers. Additionally, staff failed to document evening meal intake percentages for nine residents, potentially affecting nutritional assessments and interventions.

The facility was found deficient in multiple areas including inaccurate resident assessments, failure to provide snacks before dialysis, inadequate assistance with activities of daily living, lack of mental health services after a traumatic event, medication errors involving duplicate orders, unsecured treatment carts, serving meals at unsafe temperatures, and environmental safety issues in resident rooms and common areas.

The facility failed to secure treatment carts containing medications, leaving them unlocked and accessible, potentially affecting all 48 residents on the 300 Unit. Additionally, the facility failed to promptly notify the ordering provider of critical lab results for one resident, resulting in delayed treatment.

The complaint investigation included substantiated findings of failure to honor resident shower preferences, failure to notify physicians about wound vac malfunction, failure to maintain a safe environment, verbal and physical abuse by a CNA, failure to follow wound care orders, failure to prevent falls, and failure to provide accessible call lights.

The facility was found deficient in honoring residents' rights to shower preferences, notifying physicians about wound vacuum malfunctions, maintaining a safe and homelike environment, preventing abuse, following physician orders for wound care, ensuring resident safety from falls, and providing accessible call lights. Multiple residents experienced issues with shower facilities, wound care, environmental hazards, and abuse by staff.

The facility failed to update the care plan for one resident to include the need for a suction machine at bedside following a new physician order, potentially risking the resident's safety and well-being.

The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at the same table, inadequate language barrier interventions, missed medical appointments due to transportation issues, call lights not within reach, failure to promote resident choices, lack of notification of grievance resolutions, failure to maintain a clean and homelike environment, incomplete care plans, failure to meet professional standards for oxygen equipment care, ineffective discharge planning, inadequate restorative nursing services, failure to provide facial hair shaving assistance, insufficient activity programming, lack of communication with dialysis providers, incomplete CNA annual performance reviews, insufficient CNA in-service training, and food safety violations including improper food storage, inadequate dishwashing sanitization, and serving food at unsafe temperatures.

The investigation was complaint-driven, focusing on issues such as missed dialysis and medical appointments due to transportation failures, call lights not accessible to residents, ineffective discharge planning without proper provider orders or resident acknowledgment, and inaccurate or incomplete medical records leading to confusion about resident care and transfers.

The facility failed to ensure call lights were within reach for several residents and failed to ensure residents attended medical appointments due to transportation problems. Additionally, the facility did not develop an effective discharge plan for one resident and failed to maintain accurate medical records for another resident. These deficiencies posed risks of residents not receiving appropriate medical care and unsafe transitions.

The visit was complaint-related, triggered by concerns about late meal service times and a hypoglycemic episode in a resident. The complaint was substantiated based on record reviews, interviews, and observations confirming late meal delivery and related resident harm.

The facility failed to ensure timely meal delivery to residents, resulting in at least one resident experiencing a hypoglycemic episode. Interviews and observations confirmed meals were consistently served late, causing potential harm to residents with diabetes.

The complaint investigation focused on a resident (R #1) with a skin tear on the right arm that was not documented or treated properly. Interviews with staff and family revealed lack of physician orders, missing documentation, and inadequate wound care. The resident was sent to the hospital and did not return. Additional complaints included insufficient dietary staffing, poor food safety practices, and inadequate hydration for residents.

The facility failed to obtain physician orders or properly document and monitor a skin tear injury on a resident's right arm, resulting in inadequate treatment. Additionally, the facility lacked sufficient dietary staff, failed to maintain sanitary food service conditions, and did not ensure adequate hydration for residents, all of which posed risks to resident health and safety.

The facility failed to ensure accurate and complete documentation of resident baths/showers for one resident, potentially impacting care quality. Additionally, the facility did not maintain an effective pest control program, resulting in the presence of cockroaches and spiders, exposing residents to potential infection risks.

The complaint investigation was substantiated with findings that the facility failed to timely respond to grievances, report incidents, investigate falls, meet therapy orders, ensure safe transfers with Hoyer lifts, maintain adequate staffing, and properly train staff.

The facility failed to timely respond to resident grievances, report and investigate incidents properly, meet physician orders for therapy, ensure safe use of Hoyer lifts with adequate staff, maintain sufficient staffing levels, answer call lights timely, and properly train staff on Hoyer lift use. These deficiencies placed residents at risk of harm and inadequate care.

The facility was found deficient in multiple areas including resident dignity and respect, accommodation of resident preferences, care planning, medication management, infection control, food safety, and staff performance evaluations. Specific issues included improper terminology for residents needing dining assistance, failure to provide call light access, inadequate shower assistance, incomplete advanced directives, unsafe room temperatures, missing grievance documentation, incomplete PASRR screening, lack of dementia care planning, outdated care plans, oxygen use without orders, missing hospice documentation, hearing aid maintenance issues, inadequate dining assistance and meal documentation, unlocked medication carts with expired and unlabeled medications, improper food storage and labeling, failure to provide snacks consistently, and improper infection control during wound care.