Inspection Reports for
Gallup Nursing & Rehabilitation LLC
306 EAST NIZHONI BLVD, GALLUP, NM, 87301
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an unwitnessed fall with injury and failure to properly assess and provide care to a resident following the fall.
Complaint Details
The complaint investigation revealed that the facility failed to report an unwitnessed fall with injury for resident #1 and failed to properly assess the resident following the fall, resulting in immediate jeopardy and the resident's subsequent hospitalization and death. The complaint intake was received by the State Survey Agency on 11/20/24.
Findings
The facility failed to timely report an unwitnessed fall with injury to the State Survey Agency and failed to perform appropriate neurological assessments and follow-up care for the resident, which likely contributed to the resident's hospitalization and death. Immediate jeopardy was identified and a plan of removal was implemented.
Deficiencies (2)
Failed to timely report an unwitnessed fall with injury to the State Survey Agency.
Failed to provide appropriate treatment and care according to professional standards following an unwitnessed fall, including failure to perform neurological checks and fall risk evaluations.
Report Facts
Residents reviewed for incidents: 3
Length of cut on resident: 4
Admission date: Jul 13, 2024
Discharge date: Sep 21, 2024
Date of fall: Sep 13, 2024
Date of hospital admission: Sep 16, 2024
Date complaint intake received: Nov 20, 2024
Date of survey completion: Dec 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Verified failure to file incident report and responsible for filing reports with SSA. |
| Director of Nursing | Director of Nursing | Provided statements on expected neuro checks and conducted audits and re-education. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information about nursing shift and resident condition changes. |
Inspection Report
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration at the nursing facility.
Findings
The facility failed to meet professional standards for medication administration for one resident when staff did not administer the prescribed lactulose as ordered, potentially leading to adverse effects or lack of therapeutic benefit.
Deficiencies (1)
Staff did not administer the resident's lactulose medication as ordered, holding the dose due to loose stools despite the medication being intended to treat encephalopathy.
Report Facts
Medication dose missed: 1
Residents reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration and stated staff should not have held the lactulose dose |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards for Gallup Nursing & Rehabilitation LLC, including residents' rights, baseline care planning, medication administration, and arbitration agreement provisions.
Findings
The facility was found deficient in promoting residents' dignity and respect, timely creation of baseline care plans, proper medication administration, and ensuring binding arbitration agreements included provisions for convenient venue selection. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (4)
Failed to promote care with dignity and respect when staff closed a resident's door against his wishes without proper communication.
Failed to create a Baseline Care Plan within 48 hours of admission for a resident.
Failed to meet professional standards for medication administration by not administering lactulose as ordered.
Failed to ensure binding arbitration agreement included a provision for convenient venue selection.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 56
Residents reviewed: 3
Residents reviewed: 1
Residents signed arbitration agreement: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Manager #1 | Housekeeping Manager | Named in dignity and respect deficiency for closing resident's door |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies including door closure incident and arbitration agreement |
| DON | Director of Nursing | Interviewed regarding medication administration deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 4, 2023
Visit Reason
The inspection was conducted as an annual survey of Gallup Nursing & Rehabilitation LLC to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 8
Date: Jun 16, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident care, injury reporting, activities, restorative services, behavioral health care, medication management, food safety, and infection control at Gallup Nursing & Rehabilitation LLC.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to notify family of resident condition changes, failure to report injuries, inadequate activities, restorative services, behavioral health care, medication management, food safety, and infection control. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of resident condition changes, failure to report injuries of unknown origin, inadequate resident-centered activities, failure to provide restorative services, lack of behavioral health care follow-up, improper medication storage and labeling, unsafe food handling practices, and poor infection control practices such as inadequate hand hygiene and glove use.
Deficiencies (8)
Failed to notify resident's responsible party of significant weight loss.
Failed to report an Injury of Unknown Origin to the State Survey Agency.
Failed to implement ongoing one-to-one resident-centered activities program for a resident with physical limitations.
Failed to provide restorative services to maintain or improve range of motion for a resident.
Failed to ensure behavioral health care services were provided as ordered.
Failed to properly label and store medications and keep medication carts locked when unattended.
Failed to ensure sanitary food handling practices including proper freezer temperature logs and hand hygiene.
Failed to perform proper infection control practices including hand hygiene and glove use.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 57
Medication cart unlocked duration: 2
Medication count: 3
Medication count: 2
Medication count: 1
Expired supplies: 14
Residents census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Confirmed medication cart was unlocked and should be locked; confirmed no open dates on insulin flex pens |
| Center Nursing Executive | Center Nursing Executive (CNE) | Confirmed notification procedures, medication expiration process, infection control practices, and hand hygiene requirements |
| Activities Director | Activities Director (AD) | Discussed resident-centered activities program and resident engagement |
| Social Services Director | Social Services Director (SSD) | Confirmed no behavioral health appointment was made for resident #110 |
| RN #1 | Registered Nurse | Observed wearing gloves in hallway and confirmed hand hygiene practices |
| Certified Medication Aide #1 | Certified Medication Aide | Confirmed undated opened medications in medication carts |
| Dietary [NAME] | Dietary Staff | Confirmed missing freezer temperature logs |
Inspection Report
Routine
Deficiencies: 24
Date: Mar 17, 2022
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations including resident rights, advance directives, abuse reporting, discharge notifications, assessments, care planning, medication management, infection control, and food service.
Findings
The facility was cited for multiple deficiencies including failure to allow visitation during COVID-19 lockdown, failure to provide written information on advance directives, failure to timely report suspected abuse, failure to provide timely discharge notifications and bed hold notices, incomplete comprehensive assessments and baseline care plans, failure to provide appropriate respiratory and pain management, failure to assist with activities of daily living, failure to follow physician orders, failure to ensure food served at proper temperatures, failure to honor food preferences, failure to ensure accurate documentation, failure to hold required QAPI meetings with physician attendance, failure to maintain sanitary kitchen conditions, failure to ensure proper infection control practices, failure to designate a qualified infection preventionist, and failure to provide required abuse training to staff.
Deficiencies (24)
Failed to allow visitors for one resident during COVID-19 lockdown.
Failed to provide written information regarding advance directives to several residents.
Failed to timely report suspected abuse of one resident to proper authorities.
Failed to provide timely written transfer/discharge notices and notify Ombudsman for three residents.
Failed to provide written bed hold notices for three residents discharged to hospital.
Failed to complete comprehensive assessments within 14 days for two residents.
Failed to develop baseline care plans within 48 hours for three residents.
Failed to develop a complete care plan for one resident.
Failed to ensure respiratory care was provided by qualified staff for one resident.
Failed to adequately assist one resident with feeding.
Failed to follow physician orders to send one resident to emergency room.
Failed to ensure splint use and range of motion exercises for one resident with limited ROM.
Failed to provide nutritional care to address significant weight loss for one resident.
Failed to provide pain medication as needed for one resident with arthritis pain.
Failed to provide timely transportation for dialysis for one resident.
Failed to obtain consent and provide information on risks/benefits of psychotropic medications for one resident.
Failed to serve food at palatable temperatures for nine residents; hot food was lukewarm and cold food was not cold.
Failed to honor food preferences for one resident who does not eat meat.
Failed to maintain kitchen sanitation including improper sanitizer concentration, inadequate dish machine temperatures, unlabeled food, and inappropriate storage of staff beverages.
Failed to ensure accurate documentation of wound care treatment for one resident.
Failed to ensure QAPI committee included required members and physician attendance.
Failed to ensure proper infection prevention practices including glucometer disinfection, appropriate eye protection, and closed isolation room doors.
Failed to designate a qualified infection preventionist with specialized training.
Failed to provide abuse prohibition training for four of six staff sampled.
Report Facts
Weight loss percentage: 9.49
Dish machine temperature log entries: 78
Dish machine temperature minimum: 120
Sanitizer concentration: 1000
Medication destruction log last entry date: Last documented medication destruction log entry was early February 2022.
Number of QAPI meetings in 6 months: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN12 | Registered Nurse | Documented wound care treatment but did not complete treatment as ordered. |
| LPN60 | Licensed Practical Nurse | Ordered emergency room transfer for resident R45 but resident was not sent. |
| CNA22 | Certified Nursing Assistant | New hire without abuse prohibition training prior to providing care. |
| FSM | Food Service Manager | Responsible for kitchen sanitation and food temperature management. |
| CRC | Clinical Reimbursement Coordinator | Familiar with resident R46 pain but did not provide pain medication. |
| RNC | Regional Nurse Consultant | Confirmed no Infection Preventionist credential in facility. |
| AHR | Associate Human Resources | Verified staff training records for abuse and dementia training. |
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