Inspection Reports for Fiesta Park Wellness & Rehabilitation
8820 HORIZON BOULEVARD NE, ALBUQUERQUE, NM, 87113
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted following a complaint alleging physical abuse of resident #1 and concerns about incomplete skin assessments and inaccurate medical records for resident #4.
Complaint Details
The complaint investigation was triggered by a State Agency complaint received on 05/13/25 alleging physical abuse of resident #1, who was discharged against medical advice on 05/12/25 with bruising and injuries. The complaint also involved concerns about incomplete skin assessments and inaccurate medical records.
Findings
The facility failed to complete an initial skin assessment for resident #1 upon admission, which contributed to undetected physical abuse. Additionally, the facility failed to update and upload hospital discharge orders into the electronic medical record for resident #4, resulting in inaccurate medical records and premature discontinuation of IV antibiotics.
Deficiencies (2)
Failed to complete an initial skin assessment for resident #1 upon admission.
Failed to ensure medical records were updated with necessary documents for resident #4, including hospital discharge orders.
Report Facts
Residents reviewed for skin assessments: 3
Residents affected by skin assessment deficiency: 1
Residents reviewed for medical record accuracy: 1
Residents affected by medical record deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated he did not complete skin assessment for resident #1 upon admission |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Received incomplete hospital discharge orders for resident #4 and provided updated orders to Director of Nursing |
| Director of Nursing | Director of Nursing | Acknowledged failure to complete skin assessment for resident #1 and failure to upload updated discharge orders for resident #4 |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding resident #4's IV antibiotic treatment and hospital discharge orders |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate interventions for a resident who fell and experienced a head laceration while on blood thinners, with concerns about delayed emergency room transport.
Complaint Details
The complaint investigation found that the resident fell on 10/20/24, hit her head causing a laceration, and was on blood thinners. The resident was not taken to the hospital until nearly four hours later, despite significant bleeding. Interviews with staff and a former roommate confirmed the delay and the resident's need for staples to seal the wound. The Nurse Practitioner stated 911 should have been called immediately instead of scheduling EMS transport.
Findings
The facility failed to send the resident to the emergency room promptly after a fall resulting in a head laceration with bleeding, despite the resident being on blood thinners. The resident was found on the floor at 6:01 am but was not transported to the ER until 9:48 am, resulting in potential harm due to delayed treatment.
Deficiencies (1)
Failed to provide appropriate interventions for a resident with a head laceration and delayed emergency room transport after a fall.
Report Facts
Deficiencies cited: 1
Resident ID: 241
Medication dosage: 2.5
Dates: Oct 20, 2024
Time to transport: 3.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Contacted EMS to schedule transport for resident after fall | |
| Licensed Practical Nurse (LPN) #3 | Sent resident to ER but unclear if 911 was called | |
| Nurse Practitioner (NP) #1 | Stated 911 should have been called immediately due to resident's condition | |
| Assistant Director of Nursing (ADON) | Explained EMS scheduling process and reliance on nurse judgment |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to investigate an allegation of missing money, inadequate discharge preparation, incomplete care plan updates, medication management errors, dialysis care communication, medication administration errors, nutritional needs not being met, improper food storage and handling, and incomplete medical record documentation.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to investigate missing resident money, inadequate discharge planning, incomplete care plan updates, medication management issues, dialysis communication failures, medication administration errors, nutritional and food safety concerns, and incomplete medical record documentation.
Findings
The facility was found deficient in multiple areas including failure to investigate missing resident money, inadequate discharge planning and referral follow-up, failure to conduct required care plan meetings and update care plans, poor communication with providers regarding medication orders, failure to follow physician orders for diabetic management, missing dialysis communication forms, a high medication error rate with late administration, failure to serve meals as per dietary instructions, unsanitary food storage and handling practices, and incomplete documentation of pharmacist recommendations in medical records.
Deficiencies (9)
Failed to investigate an allegation of missing money for a resident, resulting in potential financial hardship.
Failed to provide sufficient preparation for safe transfer or discharge, including ensuring referral for home health services was received and accepted.
Failed to conduct quarterly care plan meetings and update care plans to include new medical devices and oxygen use for residents.
Failed to communicate medication discontinuation to provider, review nephrologist recommendations, and follow physician orders for diabetic management.
Failed to ensure ongoing communication and collaboration with dialysis facility, resulting in missing dialysis communication forms.
Medication administration errors observed with a 50% error rate due to late administration of medications.
Failed to serve meals as listed on meal tickets, specifically not providing a side salad as ordered.
Failed to store and serve food under sanitary conditions including unlabeled and undated food items, food stored on the floor, staff not wearing hairnets, and improper thawing of frozen meats.
Failed to maintain accurate and complete medical records, specifically lacking provider signatures and documentation of review and response to pharmacist recommendations.
Report Facts
Medication error rate: 50
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Aware of missing money allegation and investigation | |
| Social Services Assistant (SSA) #1 | Social Services Assistant | Interviewed regarding care plan meeting and discharge planning |
| Social Services Director (SSD) | Social Services Director | Interviewed regarding discharge planning and home health referrals |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding care plan updates and medication management |
| Physician Assistant (PA) #1 | Physician Assistant | Interviewed regarding medication orders and diabetic management |
| Licensed Practical Nurse (LPN) #8 | Licensed Practical Nurse | Interviewed regarding medication discontinuation communication |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Interviewed regarding use of Libre2 glucose monitor |
| Licensed Practical Nurse (LPN) #9 | Licensed Practical Nurse | Interviewed regarding use of Libre2 glucose monitor |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms |
| Certified Medication Aide (CMA) #1 | Certified Medication Aide | Observed administering medications late |
| Certified Medication Aide (CMA) #2 | Certified Medication Aide | Observed administering medications late |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding meal service and food storage |
| Dietary Aide (DA) #1 | Dietary Aide | Observed not wearing hairnet and improper food storage |
| Assistant Director of Nursing (ADON2) #2 | Assistant Director of Nursing | Reviewed pharmacist recommendations and medication orders |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care and services, medication management, behavioral health, and food service in the facility.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident preferences (refrigerator in room, shower frequency), failure to provide timely feedback on resident council grievances, inaccurate resident assessments, inadequate assistance with activities of daily living (baths/showers), insufficient behavioral health care communication and documentation, storage of expired medications, and serving meals at improper temperatures.
Deficiencies (7)
Failed to accommodate resident preferences for refrigerator in room and shower frequency.
Failed to give resident council feedback on concerns about meals and snacks.
Failed to ensure accurate smoking assessment for a resident.
Failed to provide adequate assistance with activities of daily living (baths/showers) for residents.
Failed to provide necessary behavioral health care and ensure communication with psychiatric providers.
Failed to ensure medications stored in medication rooms and emergency kits were not expired.
Failed to serve meals at safe and appetizing temperatures.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Expired medications: 4
Expired medications: 2
Expired medications: 1
Expired medications: 1
Expired medications: 4
Meal temperatures: 120
Meal temperatures: 99
Meal temperatures: 81
Meal temperatures: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed regarding refrigerator accommodation for resident #30 |
| Administrator | Administrator | Interviewed regarding refrigerator policy and resident council grievances |
| Director of Nursing | Director of Nursing | Interviewed regarding shower preferences and behavioral health care communication |
| Certified Nurse Assistant #1 | Certified Nursing Assistant | Interviewed regarding shower assistance and resident behavioral observations |
| Certified Medication Aide #1 | Certified Medication Aide | Confirmed expired medications in medication rooms and e-kits |
| Dietary Manager | Dietary Manager | Interviewed regarding meal temperatures and resident complaints |
| Social Services Director | Social Services Director | Interviewed regarding behavioral health service documentation |
| Activity Assistant | Activity Assistant | Interviewed regarding resident council grievance process |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding resident smoking status |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 4, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident safety, specifically related to an elopement incident involving Resident #1 who left the facility unsupervised and was later found deceased.
Complaint Details
The investigation was complaint-driven following Resident #1's elopement from the facility on [DATE], resulting in the resident being found deceased outside the facility. The complaint focused on inadequate risk assessment, supervision, and notification related to the resident's wandering and elopement risk. The facility was found to have failed in these areas, leading to immediate jeopardy.
Findings
The facility failed to accurately assess and reassess Resident #1's elopement risk, did not provide adequate supervision, and failed to notify appropriate staff of elopement attempts. Resident #1 eloped from the facility, was found outside with no signs of life, and was pronounced deceased. Multiple staff interviews and record reviews revealed gaps in communication, supervision, and documentation related to the resident's wandering and elopement risk.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in resident elopement and death.
Report Facts
Residents Affected: 3
Residents Affected: 1
Time elapsed: 3
Time of elopement: 13.22
Time found: 17.29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Receptionist (REC #1) | Did not observe resident eloping and was busy at front desk | |
| Clinical Intake Coordinator (CIC) | Stated facility does not have locked or memory care unit | |
| Licensed Practical Nurse (LPN #1) | Reported resident was moderate elopement risk and appeared stable initially | |
| Certified Nursing Assistant (CNA #1) | Last staff to see resident before elopement | |
| Director of Nursing (DON) | Led search efforts and confirmed resident was moderate elopement risk | |
| Licensed Practical Nurse (LPN #2) | Assisted resident to room, no indication resident wanted to leave | |
| Resident's Son | Found resident deceased outside facility | |
| Resident's Daughter | Reported resident's prior elopement attempt and communicated concerns | |
| Director of Rehab (DOR) | Communicated with resident's family and staff about elopement risk | |
| Licensed Practical Nurse (LPN #3) | Notified manager of increased wandering, later recanted statement about resident found outside | |
| Weekend Manager (WM) | Not informed of resident's increased wandering | |
| Certified Nursing Assistant (CNA #2) | Redirected resident during wandering | |
| Administrator (ADM) | Received notification of immediate jeopardy and oversaw plan of removal | |
| Receptionist (REC #2) | Busy at front desk, no recollection of resident leaving facility |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional and dietary service requirements, including timely meal service and accommodation of resident food preferences and allergies.
Findings
The facility failed to ensure timely meal service according to the posted schedule for some residents, resulting in residents receiving meals late or snacks instead. Additionally, the facility failed to provide food that accommodated a resident's dietary preferences, as a resident did not receive a loaded baked potato as ordered.
Deficiencies (2)
Failure to ensure residents receive meals in accordance with the menu schedule, causing risk of malnutrition and frustration.
Failure to provide food that accommodates resident allergies, intolerances, and preferences, risking weight loss or allergic reaction.
Report Facts
Residents reviewed during meal observations: 3
Residents affected by meal timing deficiency: 2
Residents observed for food preferences: 2
Residents affected by food preference deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed and interviewed regarding delayed meal service to Resident #2 | |
| Certified Nursing Assistant (CNA) #2 | Observed serving lunch tray to Resident #2 | |
| Certified Nursing Assistant (CNA) #3 | Interviewed about recent delays in meal delivery | |
| Certified Nursing Assistant (CNA) #4 | Interviewed about inconsistency in meal service timing | |
| Certified Nursing Assistant (CNA) #5 | Interviewed about timing of lunch delivery | |
| Dietary Manager (DM) | Interviewed regarding meal service expectations and confirmation of deficiencies |
Inspection Report
Routine
Deficiencies: 16
Date: Aug 1, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey of Fiesta Park Wellness & Rehabilitation to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including medication administration, care planning, respiratory care, restorative therapy, infection control, food service, and medication management. Specific issues included failure to assess residents' ability to self-administer medications, incomplete care plans, inadequate labeling and changing of oxygen tubing, failure to provide restorative therapy, missed showers and ADL assistance, delayed therapy services, medication errors, expired medications in storage, lack of alternative meal options, improper food storage, and infection control lapses.
Deficiencies (16)
Failed to have the Interdisciplinary Team determine if resident #173 could self-administer medication, resulting in potential harm.
Failed to update care plans for residents #37 and #40 to reflect CPAP use, stroke diagnosis, and conduct initial care plan meeting.
Failed to label, date, and change oxygen tubing weekly for residents #2 and #264 as ordered.
Failed to provide restorative therapy as ordered for residents #46 and #60, resulting in potential decline in physical abilities.
Failed to provide adequate ADL assistance for baths/showers for residents #9, #40, and #60, resulting in poor hygiene and resident dissatisfaction.
Failed to provide appropriate treatment and care for residents #37, #164, and #167, including delayed hospital transfer for stroke, inadequate pain management, and failure to identify and treat constipation.
Failed to provide respiratory care consistent with physician orders for resident #37 by not having oxygen or CPAP equipment readily available.
Failed to ensure consultant pharmacist recommendations were reviewed and implemented timely for residents #2, 9, 167, 263, and 266.
Medication error rate exceeded 5% with 3 errors out of 25 opportunities for residents #15, 35, and 173 during medication administration.
Failed to ensure medications were administered per prescriber's order for resident #173, including Creon medication given after meal instead of before.
Failed to ensure medications in medication carts and storage rooms were not expired, with multiple expired medications observed.
Failed to ensure nutritional needs and preferences were met by not providing alternative meals or substantial always available menu for residents.
Failed to provide snacks consistently and timely for all residents, with limited snack options and lack of diabetic-friendly snacks.
Failed to store and serve food under sanitary conditions including unlabeled and undated food items, improper storage, ice and water puddles on freezer floor, staff food in resident refrigerators, and dirty dry storage floor.
Failed to provide physical therapy services as ordered for resident #9, resulting in psychosocial harm and despair.
Failed to maintain proper infection prevention measures by storing resident #40's suction equipment uncovered on the floor and leaving a used blood glucose test strip on the hallway floor.
Report Facts
Medication error rate: 12
Residents affected by medication regimen review deficiency: 5
Residents affected by restorative therapy deficiency: 2
Residents affected by ADL assistance deficiency: 3
Residents affected by infection prevention deficiency: 1
Residents affected by respiratory care deficiency: 1
Residents affected by medication administration deficiency: 1
Residents affected by food service deficiency: 1
Residents affected by physical therapy deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNP #1 | Certified Nurse Practitioner | Named in relation to delayed hospital transfer and stroke diagnosis for resident #37 |
| VPCO | President of Clinical Operations | Named in relation to resident #37 hospital transfer and infection control |
| DON | Director of Nursing | Named in relation to multiple findings including medication administration, respiratory care, infection control, and food service |
| DM | Dietary Manager | Named in relation to food service deficiencies |
| DOR | Director of Rehab | Named in relation to delayed therapy services for resident #9 |
| ST #1 | Speech Therapist | Named in relation to delayed therapy services for resident #9 |
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