Inspection Reports for
Los Alamos Wellness & Rehabilitation

The complaint investigation substantiated multiple deficiencies including failure to notify providers of wound changes, failure to monitor wounds and follow orders, improper medication storage, and falsification of wound care documentation. Immediate jeopardy was identified related to pressure ulcer care but was removed after corrective actions.

The facility failed to timely notify providers of worsening wounds, failed to monitor wounds weekly and follow physician orders, failed to provide appropriate pressure ulcer care leading to worsening wounds and hospitalizations, failed to secure medication carts, and falsified wound care documentation. Immediate jeopardy was identified but later removed after corrective actions.

The facility failed to ensure all food items were labeled and dated, and daily refrigerator temperatures were not documented. These deficiencies could potentially cause foodborne illnesses affecting 22 residents.

The complaint investigation involved allegations of abuse by a Registered Nurse (RN) toward a resident (R #1) on 12/30/24, including yelling and pushing. Witnesses reported the incident, but the nurse was not removed from resident care. The Administrator conducted a limited investigation, reviewed video footage unavailable to the State Agency, and concluded abuse had not occurred. The incident was not reported to the State Survey Agency. Additional complaints included failure to safeguard resident PHI, inadequate supervision leading to falls, unlocked medication carts, and unsanitary food storage.

The facility was found deficient in safeguarding resident personal health information, protecting residents from abuse, timely reporting suspected abuse to the State Survey Agency, conducting thorough abuse investigations, ensuring adequate supervision to prevent accidents, securing medication carts, and maintaining sanitary food storage conditions.

The facility was found deficient in multiple areas including inconsistent advance directive documentation, failure to notify providers and family of resident condition changes, inadequate care plan updates, failure to provide timely behavioral health services, medication regimen review deficiencies, improper medication disposal, inadequate food service practices, inaccurate medical records, and non-functioning call light systems.

The facility was found deficient in maintaining comfortable water temperatures in resident shower rooms, providing nourishing bedtime snacks, ensuring sanitary food storage and preparation, and maintaining a functioning call light system. These deficiencies affected many or all of the 63 residents present during the inspection.

The complaint investigation found that resident #1 did not receive prescribed pain medication Pregabalin on four scheduled times, leading to unmanaged pain and a 911 call. The deficiency was substantiated with interviews and record reviews.

The facility failed to administer prescribed Pregabalin medication to resident #1 on four scheduled occasions, resulting in unmanaged pain that led the resident to call 911 and be transported to the hospital. The Director of Nursing acknowledged the medication was not administered as ordered.

The facility failed to ensure one resident (R #3) was bathed according to her preferences, resulting in poor hygiene and loss of dignity. Additionally, the facility failed to properly monitor and manage medications for the same resident, administering stool softeners on days when diarrhea was present, which could lead to adverse outcomes.

The investigation was complaint-driven, focusing on fall prevention, ADL assistance, and infection control failures. The report indicates minimal harm with few residents affected.

The facility failed to implement fall prevention measures for a high-risk resident, did not provide adequate assistance with bathing and showers, and staff failed to use proper personal protective equipment when entering the room of a COVID-19 positive resident. These deficiencies posed risks of harm, dignity loss, and infection spread.

The facility was found deficient in multiple areas including failure to post survey results accessibly, discrepancies in advance directives, failure to timely report abuse, inadequate therapeutic diet provision, incomplete medical records, improper medication storage, lack of alternative meal options, incomplete infection control program, obstructed hallways, and incomplete CNA annual competencies.

The complaint investigation substantiated that an agency CNA attempted to steal a resident's credit cards and that the facility failed to safeguard the resident's belongings. Additionally, the facility failed to report a curling iron burn incident within the required timeframe and failed to update the resident's care plan to include fall prevention measures.

The facility failed to safeguard a resident's belongings resulting in theft by an agency CNA, failed to report a curling iron burn incident to the State Survey Agency within 5 working days, and failed to update the care plan for a resident to include fall prevention interventions despite the resident being at high risk for falls.

The inspection identified multiple deficiencies including failure to maintain accessible advanced directives, inadequate assistance with activities of daily living, incomplete care plans, improper medication management, failure to provide timely dental care, unsafe food handling practices, improper infection control mask usage, incomplete staff COVID-19 vaccination documentation, and unsafe hallway conditions.