Inspection Reports for Las Estancias by Pure Health
3620 LAS ESTANCIAS DR SW, ALBUQUERQUE, NM, 87121
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 21, 2025, found multiple deficiencies related to care planning, medication monitoring, meal quality, respiratory care, vaccination offerings, and nurse aide training. Earlier inspections and complaint investigations also identified issues with medication management, infection control, pain management, and care coordination, including substantiated complaints about improper psychotropic medication use and delayed pain treatment that caused harm. Inspectors cited recurring themes of incomplete or inaccurate care plans, medication errors, and lapses in infection prevention and resident care practices. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern of deficiencies suggests ongoing challenges with clinical care and compliance, with no clear indication of sustained improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Feb 21, 2025
Visit Reason
The inspection was conducted as part of a comprehensive annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including inaccurate PASRR screening, incomplete and inaccurate care plans, failure to monitor antibiotic stop dates, poor meal quality and food safety, inadequate respiratory care, failure to offer influenza and COVID-19 vaccinations, and lack of required in-service training for nurse aides.
Deficiencies (10)
Failed to ensure accurate PASRR screening for mental disorders or intellectual disabilities for 1 of 4 residents reviewed.
Failed to develop and implement a complete, person-centered care plan for 4 of 9 residents reviewed, including lack of care plans for bed rail use and antibiotic management.
Failed to revise the care plan within 7 days of comprehensive assessment for 1 resident, including fall prevention, oxygen therapy, and vision loss interventions.
Failed to monitor antibiotic stop dates for 1 resident, risking antibiotic overuse and resistance.
Failed to ensure meals were palatable, attractive, and served at safe temperatures for 8 of 10 residents reviewed.
Failed to maintain sanitary conditions in the kitchen including unlabeled/dated food items, unclean countertops, shelves, floors, and heated plate dispenser.
Failed to provide respiratory care consistent with professional standards by not changing nasal cannulas within seven days for 2 of 5 residents reviewed.
Failed to offer influenza vaccination to 1 of 5 residents reviewed for immunizations.
Failed to offer COVID-19 vaccination to 1 of 5 residents reviewed for immunizations.
Failed to ensure Certified Nurse Aides received required annual in-service training for 3 of 5 CNAs reviewed.
Report Facts
Residents reviewed for PASRR accuracy: 4
Residents reviewed for care plans: 9
Residents reviewed for respiratory care: 5
Residents reviewed for immunizations: 5
Residents reviewed for meal quality: 10
Certified Nurse Aides reviewed for training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Confirmed lack of CNA ongoing training and expectations for 12 hours per year |
| DON | Director of Nursing | Confirmed inaccuracies in PASRR, care plan deficiencies, antibiotic monitoring, vaccination offerings |
| Assistant Director of Nursing-Facility Wide | ADON-FW | Confirmed nasal cannula change practices and documentation |
| CNA #6 | Certified Nursing Assistant | Confirmed nasal cannula change practices |
| Culinary Supervisor | Culinary Supervisor | Confirmed meal quality complaints and food appeal issues |
| Culinary Manager | Culinary Manager | Confirmed kitchen sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Nov 17, 2023
Visit Reason
The inspection was conducted based on complaints regarding the improper use of psychotropic medications, improper medication storage, and failure to maintain infection prevention measures.
Complaint Details
The complaint investigation found substantiated deficiencies related to psychotropic medication use without proper diagnosis, medication storage issues affecting 54 residents, and infection control lapses involving PPE and hand hygiene.
Findings
The facility failed to ensure antipsychotic medications were prescribed with a corresponding active diagnosis, improperly stored medications in medication carts risking expired or ineffective drugs for 54 residents, and failed to maintain proper infection prevention measures including PPE use and hand hygiene.
Deficiencies (3)
Failed to maintain a process ensuring antipsychotic medications are prescribed to treat a specific diagnosed condition.
Failed to properly store medications in medication carts, risking expired or improperly temperature-controlled medications.
Failed to maintain proper infection prevention measures including not wearing proper PPE and not performing hand hygiene between residents.
Report Facts
Residents affected by medication storage deficiency: 54
Residents affected by infection prevention deficiency: 36
Residents reviewed for psychotropic medication use: 2
Residents affected by psychotropic medication deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding psychotropic medication diagnosis, medication storage policy, and infection prevention practices | |
| Clinical Specialist | Interviewed regarding psychotropic medication diagnosis | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about medication cart storage policy | |
| Certified Medication Aide (CMA) #1 | Interviewed about medication cart storage policy | |
| Central Supply Aide (CS) | Observed not wearing proper PPE and not performing hand hygiene | |
| Nurse Practitioner | Checked box for schizophrenia diagnosis in EHR |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding medication reconciliation errors during resident discharge and failure to follow physician's orders to create referrals for specialist appointments.
Complaint Details
The complaint investigation found that two residents (R #265 and R #6) were affected by the deficiencies. The medication reconciliation failure led to a resident receiving another resident's blood thinner medication, and the referral failure resulted in a missed endocrinology appointment for a resident with persistent low TSH levels.
Findings
The facility failed to properly reconcile medications during discharge, resulting in a resident receiving another resident's medication, and failed to follow physician's orders to create a referral for an endocrinology appointment for a resident. These deficiencies posed potential harm to residents.
Deficiencies (2)
Failure to reconcile medications during discharge, resulting in a resident receiving medication that did not belong to her.
Failure to follow physician's order to create a referral for an endocrinology specialist appointment.
Report Facts
Residents reviewed for safe discharge and disease management: 5
Residents affected by deficiencies: 2
Date of resident discharge: Oct 11, 2023
Date of physician order for referral: Aug 4, 2023
Date of physician visit documentation: Nov 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #1 | Explained the medication reconciliation process and acknowledged the nurse gave a medication that did not belong to resident R #265. | |
| Appointment Scheduler | Confirmed that resident R #6 did not have an endocrinology appointment scheduled due to not receiving a referral form. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 10, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to provide appropriate pain management to a resident (R #1) who experienced a fall and subsequent fracture, resulting in prolonged and undue pain.
Complaint Details
The complaint investigation revealed that the resident fell on 05/14/23 and complained of severe left hip pain. Despite an x-ray showing no fracture, the resident's pain worsened, and an MRI later confirmed a fracture. The facility failed to administer prescribed Oxycodone due to lack of order entry and medication availability. The resident's family requested hospital transfer multiple times before it occurred on 05/15/23. Interviews with staff confirmed the failure to implement pain management orders and delayed response to the resident's pain.
Findings
The facility failed to recognize, respond to, and treat a significant injury in a timely manner, resulting in actual harm to the resident. Despite a fall and severe pain complaints, pain medication orders were not implemented, and the resident experienced prolonged discomfort before being sent to the hospital where a fracture was diagnosed by MRI.
Deficiencies (1)
Failure to provide safe and appropriate pain management for a resident requiring such services, resulting in actual harm.
Report Facts
Pain level: 4
Medication dose: 5
Medication dose: 2.5
Medication dose: 0.5
Medication dose: 325
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #1 | Nurse Practitioner | Ordered Oxycodone for pain management but order was not entered or administered |
| NP #2 | Nurse Practitioner | Assessed resident on 05/15/23, confirmed pain and directed hospital transfer |
| Interim Director of Nursing | Director of Nursing | Confirmed fall and failure to administer prescribed pain medication; interviewed regarding incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pain management for a resident (R #1) who experienced a fall and subsequent fracture.
Complaint Details
The complaint investigation revealed that the resident fell on 05/14/23 and complained of severe left hip pain. An x-ray was negative for fracture, but an MRI later confirmed a fracture. The provider ordered Oxycodone for pain management, but no order was entered or medication administered. The resident experienced significant pain for approximately 24 hours without relief. Family requested hospital transfer multiple times before it occurred on 05/15/23. Interviews with staff confirmed the failure to implement pain management orders and delayed hospital transfer.
Findings
The facility failed to recognize, respond to, and treat a significant injury in a timely manner, resulting in prolonged and undue pain for the resident. Despite a fall and severe pain complaints, pain medication orders were not implemented, and the resident was not promptly sent to the hospital until the following day after a physical therapy assessment.
Deficiencies (1)
Failure to provide safe, appropriate pain management for a resident who requires such services.
Report Facts
Pain level: 4
Medication dose: 0.5
Medication dose: 325
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #1 | Nurse Practitioner | Ordered Oxycodone for pain management but order was not entered or administered |
| NP #2 | Nurse Practitioner | Assessed resident on 05/15/23, requested physical therapy assessment, and directed hospital transfer |
| Interim Director of Nursing | Director of Nursing | Confirmed fall and failure to implement pain management orders; interviewed regarding incident |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 22, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication administration, care planning, dialysis services, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of low oxygen saturation and medication conflicts, lack of baseline and comprehensive care plans for residents, inconsistent medication administration and availability, inadequate monitoring of dialysis sites, failure to provide timely medication delivery, incomplete medical records, and failure to assist residents with assistive devices and activities of daily living.
Deficiencies (11)
Failure to notify the physician of oxygen saturation levels falling below normal and failure to notify the physician of a conflict with a resident's dialysis schedule and medication administration for 3 residents.
Failure to develop a baseline care plan within 48 hours after admission including minimum healthcare information for 3 residents.
Failure to develop and implement a comprehensive person-centered care plan for 2 residents diagnosed with dementia and hearing impairment.
Failure to provide care and treatment in accordance with professional standards for medication administration for 1 resident.
Failure to provide activities of daily living assistance with trimming toenails for 1 resident.
Failure to assist a resident in gaining access to vision and hearing services and maintain proper assistive devices.
Failure to have physician orders for monitoring the dialysis shunt site for 1 resident.
Failure to provide medications as per physicians' orders due to unavailability of medications for 2 residents.
Failure to ensure medication error rates did not exceed 5% by failing to give ordered medications timely for 2 residents, resulting in an error rate of 17.5%.
Failure to safeguard resident-identifiable information and maintain complete and accurate medical records for 3 residents.
Failure to ensure a licensed pharmacist performed a monthly drug regimen review including documentation of rationale for not following pharmacist recommendations for 1 resident.
Report Facts
Medication error rate: 17.5
Medication doses missed: 7
Residents reviewed for care plans: 4
Residents reviewed for dialysis care: 3
Medication administration errors: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding oxygen saturation notification and medication administration. |
| Unit Manager #3 | Unit Manager | Interviewed regarding oxygen saturation notification and medication administration. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, care plans, dialysis orders, and medication availability. |
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Interviewed regarding hearing aids and care planning. |
| Certified Medication Aide #2 | Certified Medication Aide | Interviewed regarding medication availability and administration. |
| Assistant Director of Nursing #3 | Assistant Director of Nursing | Interviewed regarding medication availability and administration. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding hearing aids. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding toenail care. |
| Case Manager #1 | Case Manager | Interviewed regarding wheelchair repair and social services. |
| Administrator | Administrator | Interviewed regarding wheelchair repair and facility payment. |
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