Deficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician of critical lab and chest x-ray results for resident #7 following a change in condition.
Complaint Details
The complaint investigation found that staff did not notify the physician of abnormal lab results and chest x-ray findings for resident #7 on 11/26/24. The physician was only notified on 11/29/24 after which treatment was ordered. Resident #7 was found unresponsive and passed away on 11/30/24. The physician confirmed that earlier notification would have led to earlier treatment and possibly prevented the outcome.
Findings
The facility failed to notify the physician of the results of resident #7's chest x-ray, complete blood count, and comprehensive metabolic panel after a change in condition, which likely delayed treatment for pneumonia and contributed to the resident's death. The facility implemented an Improvement Action Plan including staff education, process changes for diagnostic result delivery, and tracking improvements.
Deficiencies (1)
Failure to notify the physician of critical lab and chest x-ray results for resident #7 following a change in condition, resulting in delayed treatment for pneumonia and likely contributing to the resident's death.
Report Facts
Red blood cell count: 2.37
Hemoglobin: 8.4
Hematocrit: 25.2
Sodium: 124
Potassium: 2.8
Chloride: 95
Medication order: 250
Medication dosage: 20
Medication dosage: 40
Medication dosage: 10
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member #1 | Received lab results on 11/26/24 and emailed them to Director of Nursing and Assistant Director of Nursing | |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged failure to notify physician of lab results on 11/26/24 and described process changes |
| Director of Nursing | Director of Nursing | Confirmed process changes for diagnostic result delivery and tracking implementation |
| Resident #7's Physician | Physician | Stated staff did not notify him of abnormal lab and x-ray results timely; confirmed that earlier notification would have led to earlier treatment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
The inspection was conducted following a complaint regarding a Certified Nursing Assistant (CNA) instructing a resident (R #3) to use her brief instead of assisting her to the bathroom, potentially violating resident dignity and rights.
Complaint Details
The complaint was substantiated. The CNA was suspended during the investigation and retrained on dignity and resident rights. The facility found the allegations to be a lack of dignity, against resident rights, and against facility policy.
Findings
The facility failed to assist resident R #3 with activities of daily living, specifically toileting, despite the resident not being non-weight bearing. The CNA told the resident to use her brief instead of the toilet, which was against the care plan and resident rights. The facility took immediate corrective action including retraining staff and suspending the CNA pending investigation.
Deficiencies (1)
Failure to assist resident R #3 with toileting as required, instructing her to use her brief instead of the toilet.
Report Facts
Residents reviewed for ADLs: 3
Residents affected: 1
Dates of training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in toileting assistance deficiency and retraining |
| CNA #4 | Certified Nursing Assistant | Provided statement about resident toileting practices |
| Interim Director of Nursing | Director of Nursing | Issued corrective action memo regarding the incident |
| Corporate Nurse | Corporate Nurse | Interviewed regarding resident toileting and staff practices |
| Activities Assistant | Activities Assistant | Interviewed about resident call light and toileting |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and failure to report incidents involving residents and staff at Aztec Healthcare.
Complaint Details
The complaint investigation was substantiated with findings of abuse by CNA #4 against multiple residents, failure to report abuse incidents and follow-up investigations to the State Agency, and failure to meet professional standards of care and safety.
Findings
The facility failed to protect residents from abuse by staff, including emotional trauma and physical abuse by a Certified Nurse Aide (CNA #4) affecting multiple residents. The facility also failed to timely report suspected abuse and submit required follow-up reports to the State Agency. Additionally, the facility failed to meet professional standards of quality and ensure resident safety related to supervision and accident prevention.
Deficiencies (5)
Failure to prevent emotional trauma by not immediately removing a deceased roommate's body or moving the resident.
Physical abuse by CNA #4 to residents including kicking, hitting, shoving, and causing bruising.
Failure to timely report suspected abuse and submit five day follow-up reports to the State Agency for multiple residents.
Failure to meet professional standards of quality due to staff neglect and inadequate care on 100 and 200 hallways.
Failure to ensure resident safety by leaving fall mats on the floor when resident was not in bed and failure to check wanderguard placement for a resident at risk of elopement.
Report Facts
Residents reviewed for abuse: 7
Residents affected by abuse: 5
Blood Alcohol Content (BAC): 0.209
Number of smoke breaks: 5
Length of break: 2.5
Resident BIMS score: 7
Resident elopement risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Named in multiple abuse findings including physical abuse and neglect |
| Assistant Director of Nursing | ADON | Interviewed regarding abuse incidents and reporting failures |
| Director of Nursing | DON | Interviewed regarding abuse findings and staff suspensions |
| Nurse #7 | Nurse | Reported resident intoxication and staff misconduct |
| Nurse #8 | Nurse | Notified ADON of missing resident and staff |
| CNA #5 | Certified Nurse Aide | Involved in staff misconduct with CNA #4 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, medication administration, care planning, and safety in the nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to properly document and allow self-administration of medications, failure to prevent resident abuse by staff including physical and emotional abuse, failure to timely report abuse incidents to the State Agency, failure to develop comprehensive care plans addressing fall interventions, failure to meet professional standards of quality in staffing and supervision, and failure to ensure safety measures such as proper use of fall mats and wanderguards to prevent accidents and elopement.
Deficiencies (6)
Failed to have the Interdisciplinary Team determine if residents could self-administer medication, resulting in inappropriate self-administration.
Failed to protect residents from abuse including emotional trauma and physical abuse by a Certified Nurse Aide affecting multiple residents.
Failed to timely report suspected abuse and submit required follow-up reports to the State Agency for multiple residents.
Failed to develop a comprehensive care plan including fall interventions such as use of fall mats for a resident.
Failed to meet professional standards of quality for residents on two hallways, including staff neglect and inappropriate behavior such as leaving residents unattended and smoking with a resident.
Failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, including failure to remove fall mats when resident was not in bed and failure to check wanderguard placement leading to resident elopement.
Report Facts
Residents reviewed for abuse: 7
Residents affected by abuse: 4
Blood Alcohol Content (BAC): 0.209
Fall mats observed: 2
Residents reviewed for care plans: 1
Residents reviewed for accident prevention: 2
BIMS score: 7
Elopement risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Named in multiple abuse findings including physical abuse and neglect |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication self-administration and abuse incidents |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding abuse incidents, reporting failures, and staff suspensions |
| Nurse #7 | Nurse | Reported resident intoxication and staff misconduct |
| Nurse #8 | Nurse | Reported resident missing and staff misconduct |
| CNA #5 | Certified Nurse Aide | Named in staff misconduct and abuse findings |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 5, 2024
Visit Reason
The inspection was conducted to assess compliance with baseline care planning and infection prevention and control practices at the facility.
Findings
The facility failed to create an accurate Baseline Care Plan within 48 hours of admission for one resident, and failed to ensure collection bags were kept off the floor for two residents, posing risks for infection.
Deficiencies (2)
Failed to create an accurate Baseline Care Plan including catheter care within 48 hours of admission for 1 of 3 residents reviewed.
Failed to provide proper infection control practices by allowing collection bags to lie on the floor for 2 of 3 residents.
Report Facts
Residents reviewed for baseline care plans: 3
Residents affected by baseline care plan deficiency: 1
Residents affected by infection control deficiency: 2
Antibiotic dosage: 500
Antibiotic treatment duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed and confirmed deficiencies related to baseline care plan and infection control practices |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 10, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to care planning, pressure ulcer care, medication administration, and food handling practices at Aztec Healthcare nursing home.
Findings
The facility failed to create timely and comprehensive baseline and ongoing care plans for residents, failed to provide appropriate pressure ulcer care resulting in necrotic wounds, administered incorrect medication doses, and did not maintain sanitary conditions when serving meals to residents in their rooms.
Deficiencies (5)
Failed to create an accurate Baseline Care Plan within 48 hours of admission for a resident.
Failed to develop and implement a comprehensive care plan within 7 days of assessment and failed to include resident or representative in care plan meetings.
Failed to provide necessary treatment and service to prevent development and promote healing of pressure wounds, resulting in necrotic pressure ulcer.
Administered wrong medication dose (Buspirone 30 mg instead of 15 mg) to a resident.
Failed to distribute food under sanitary conditions by transporting uncovered resident meals to rooms.
Report Facts
Residents reviewed for Baseline Care Plans: 8
Residents reviewed for comprehensive care plans: 3
Residents reviewed for pressure ulcers: 3
Residents reviewed for medication errors: 10
Resident meals served in rooms: 76
Buspirone dose administered: 30
Buspirone dose ordered: 15
Braden Scale score: 12
Pressure ulcer wound size: 4.3
Pressure ulcer wound size: 3.5
Pressure ulcer wound size: 3
Pressure ulcer wound size: 3.2
Pressure ulcer wound depth: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Administered wrong medication dose to Resident #23 and provided interview confirming error |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding baseline care plan for Resident #60 |
| Social Services Assistant | Social Services Assistant | Interviewed regarding care planning meetings for Resident #35 |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding pressure ulcer wounds for Resident #19 |
| Director of Nursing | Director of Nursing | Interviewed regarding notification and treatment of pressure ulcer wounds for Resident #19 |
| Physician | Physician | Interviewed regarding pressure ulcer wounds and treatment orders for Resident #19 |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed regarding skin monitoring and notification for Resident #19 |
| Certified Nursing Aide #1 | Certified Nursing Aide | Observed and interviewed regarding uncovered food transport during meal service |
Inspection Report
Routine
Deficiencies: 16
Date: Jan 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication administration, care planning, dietary services, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, inadequate medication self-administration assessments, failure to support resident self-determination, inaccurate advance directives documentation, inaccurate resident assessments, incomplete care plans, failure to meet professional standards of care, inadequate assistance with activities of daily living, failure to provide proper assistive devices, incomplete pharmacist medication reviews, improper medication storage and labeling, failure to maintain safe food temperatures and follow menus, failure to provide mechanically altered diets as ordered, unsanitary food storage and preparation conditions, and failure to maintain proper infection prevention measures.
Deficiencies (16)
Failure to promote care with dignity and respect by not knocking before entering resident rooms.
Failure to have Interdisciplinary Team determine if residents could self-administer medication.
Failure to promote resident self-determination through support of resident choice.
Failure to ensure New Mexico Medical Orders For Scope of Treatment (NM MOST) forms and physician orders matched and were signed timely.
Failure to ensure accurate Minimum Data Set (MDS) assessments reflecting resident discharge status.
Failure to develop and implement comprehensive person-centered care plans for oxygen use and skin rash.
Failure to meet professional standards of care including oxygen administration and physician orders for Foley catheter.
Failure to provide activities of daily living (ADL) assistance for baths/showers as scheduled.
Failure to assist resident in gaining access to vision and hearing services, including failure to obtain new glasses.
Failure to ensure monthly drug regimen review by licensed pharmacist for all residents.
Failure to ensure medications were not expired, properly labeled, and stored; refrigerator temperature logs incomplete.
Failure to ensure safe food serving temperatures, including unheated potatoes and improperly refrigerated cranberry dessert.
Failure to follow menus, provide alternative meals, and honor resident food preferences, resulting in residents receiving fast food.
Failure to provide mechanically altered diet as ordered for resident.
Failure to store and serve food under sanitary conditions including improper food storage, expired foods, dirty kitchen, unlabeled nourishment food, improper cleaning, incomplete temperature logs, and staff not wearing hair nets.
Failure to maintain proper infection prevention measures including staff not wearing masks properly or at all times.
Report Facts
Residents reviewed for ADL care: 6
Residents reviewed for medication regimen: 5
Residents affected by infection prevention deficiencies: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Observed not properly wearing N95 mask and entering resident rooms without knocking | |
| Certified Nursing Assistant #1 | CNA | Observed entering resident rooms without knocking |
| Certified Nursing Assistant #5 | CNA | Observed not wearing mask at nurses station |
| Registered Nurse #2 | RN | Observed wearing surgical mask below nose |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including infection control and medication reviews |
| Licensed Pharmacist | RPh | Interviewed regarding monthly medication regimen reviews |
| Dietary Manager | DM | Interviewed regarding food temperature logs, menu adherence, and kitchen sanitation |
| MDS Coordinator | MDSC | Interviewed regarding pureed diet consistency |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding shower schedule and staffing |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding oxygen use and shower schedule |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication self-administration |
| Assistant Director of Nursing | ADON | Interviewed regarding Foley catheter orders |
| Corporate Nurse | CN | Interviewed regarding resident visitation restrictions |
| Business Office Manager | BOM | Interviewed regarding resident glasses purchase |
| Admissions/Transport | A/T | Interviewed regarding resident glasses purchase |
| Dietary Aide #1 | DA | Observed not wearing hairnet in dish room |
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