Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
163% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 17, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication use, physical restraints, and infection prevention and control.
Findings
The facility was found deficient in ensuring residents were free from physical and chemical restraints without proper justification, including inappropriate use of Haldol injections administered under restraint. Additionally, the facility failed to implement an adequate Legionella Water Management Program to minimize the risk of Legionella in the water system, potentially affecting all residents.
Deficiencies (3)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Provide and implement an infection prevention and control program, specifically an adequate Legionella Water Management Program.
Report Facts
Medication administrations: 8
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #4 | Nurse | Named in relation to physically restraining resident #10 to administer medication |
| Unit Manager | Unit Manager (UM) of Floor 200 | Interviewed regarding restraint practices and expectations for resident #10 |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Held resident #10 down during medication administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed about restraint practices and medication adjustments for resident #10 |
| Physician Assistant | Physician Assistant (PA) | Provided clinical assessment and medication orders for resident #10 |
| Social Services Assistant | Social Services Assistant (SSA) | Interviewed regarding resident #10's behavior and statements |
Inspection Report
Routine
Census: 291
Deficiencies: 16
Date: Jul 25, 2025
Visit Reason
The facility underwent a routine inspection to assess compliance with regulatory requirements related to resident care, safety, medication management, environment, infection control, and other operational standards.
Findings
The inspection identified multiple deficiencies including failure to obtain consent for psychotropic medications, inadequate advance directive updates, unsafe and unclean environment conditions, incomplete and inaccurate resident assessments and care plans, improper medication use, failure to follow physician orders, unsafe smoking practices with oxygen use, infection control lapses, pest infestation, and insufficient staff training.
Deficiencies (16)
Failed to ensure residents and/or their representatives were informed and consented to psychotropic medications for 1 resident.
Failed to update/revise advance directives for 1 resident, risking unwanted life-saving measures.
Failed to provide a safe, clean, comfortable, and homelike environment; multiple maintenance and cleanliness issues observed affecting 291 residents.
Failed to complete quarterly Minimum Data Set (MDS) assessment within required timeframe for 1 resident.
Failed to ensure accuracy of MDS assessments for 1 resident regarding medication use.
Failed to create accurate baseline care plans within 48 hours of admission for 2 residents.
Failed to develop comprehensive care plans addressing all resident needs for 4 residents.
Failed to revise care plans timely to include use of bed rails and pain management for 3 residents.
Failed to follow physician orders for bilateral bed rails for 1 resident.
Failed to ensure safe use of bed rails including risk assessment and informed consent for 2 residents.
Failed to protect residents from accident hazards related to smoking materials and oxygen use, resulting in Immediate Jeopardy that was removed after corrective action.
Failed to utilize proper infection control practices including equipment disinfection and adherence to contact and enhanced barrier precautions.
Failed to provide routine dental services annually for 2 residents.
Failed to properly cover trash receptacles to minimize odors and prevent pest infestation.
Failed to maintain an effective pest control program, allowing insect infestation in resident rooms.
Failed to ensure Certified Nurse Aides received required annual in-service training hours.
Report Facts
Residents affected: 291
Residents with independent smoking privileges: 53
Residents reviewed for unnecessary medications: 4
Residents reviewed for care plan deficiencies: 5
Residents reviewed for bed rail issues: 3
Residents reviewed for dental services: 2
Residents reviewed for pest infestation: 3
CNAs reviewed for in-service training: 5
CNAs not completing required training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM2 | 2nd floor unit manager | Confirmed lack of consent for psychotropic medications and medication indication mismatches |
| UM | Unit Manager | Confirmed nasal cannula replacement expectations and infection control practices |
| CNA #1 | Certified Nursing Assistant | Described nasal cannula care and infection control practices |
| DON | Director of Nursing | Confirmed care plan deficiencies and trapeze bar care plan absence |
| UM #1 | Unit Manager | Confirmed failure to follow physician orders for bed rails |
| UM #2 | Unit Manager | Confirmed care plan deficiencies and smoking policy issues |
| Maintenance Director | Confirmed smoking area supervision lapses and oxygen safety concerns | |
| Corporate Nurse | Confirmed smoking education and policy limitations | |
| Respiratory Therapist | Confirmed smoking education and oxygen safety | |
| Smoking Attendant | Described smoking material management and policy enforcement | |
| HRD | Human Resources Director | Confirmed CNA training deficiencies |
| RN #32 | Registered Nurse | Observed infection control lapses with blood pressure cuff and PPE use |
| LPN #73 | Licensed Practical Nurse | Incorrect statements about contact isolation PPE use |
| ICN | Infection Control Nurse | Confirmed infection control expectations and policy |
| DOSS | Director of Social Services | Confirmed lack of dental appointments for residents |
| SS #1 | Social Services Staff | Confirmed dental appointment referral process and policy |
Inspection Report
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards regarding documentation and administration of pain medication to a resident.
Findings
The facility failed to document the administration of oxycodone pain medication to one resident, which could cause confusion among staff and potential harm if the medication was administered again. The resident had a contusion with pain, was prescribed oxycodone, and the medication was administered but not recorded on the medication administration record.
Deficiencies (1)
Failure to document administration of pain medication (oxycodone) to resident R #1 on the medication administration record.
Report Facts
Pain level rating: 7
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #15 | Nurse | Administered oxycodone to resident R #1 but forgot to document on the MAR. |
| Director of Nursing | Director of Nursing | Stated staff should always document medication administration on the MAR. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 21, 2025
Visit Reason
The inspection was conducted due to allegations of neglect, abuse, and injury of unknown origin involving three residents (R #4, R #5, and R #6). The facility was reviewed for failure to complete thorough investigations and submit required follow-up reports to the State Survey Agency.
Complaint Details
The complaint involved allegations of neglect, abuse, and injury of unknown origin for three residents. The facility failed to investigate and submit required follow-up reports within the mandated five-day period. The State Agency received some reports late and has not received required addendums. The Administrator confirmed these failures during interviews.
Findings
The facility failed to complete and document thorough investigations, implement preventive measures, and submit timely five-day follow-up reports for the three residents involved in abuse and neglect allegations. The Administrator verified that investigations and follow-up reports were not completed or submitted as required.
Deficiencies (1)
Failure to complete and submit thorough follow-up reports regarding allegations of neglect, abuse, and injury of unknown origin for residents R #4, R #5, and R #6.
Report Facts
Residents reviewed for abuse and neglect allegations: 3
Five-day follow-up report delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | ADM | Verified staff did not complete investigations or submit five-day follow-up reports for residents R #4, R #5, and R #6 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding medication handling, medication cart security, and facility safety conditions.
Complaint Details
The visit was complaint-related, focusing on medication handling, medication cart security, and environmental safety. The report does not explicitly state substantiation status.
Findings
The facility failed to ensure medications were not left unattended on bedside tables, medication carts were locked when unattended, and that flooring was safe and level in resident rooms. These deficiencies posed potential harm to residents.
Deficiencies (3)
Staff left medications on the bedside table for one resident, risking misplacement or missed doses.
Medication carts were found unlocked and unattended, risking resident safety.
Flooring in a resident's room was uneven with missing tiles, creating an unsafe environment.
Report Facts
Medication dosage: 20
Medication dosage: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication left on bedside table and medication cart security |
| Maintenance Director | Maintenance Director | Interviewed regarding flooring condition and cause of uneven floor |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 30, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a resident's Power of Attorney about an injury, failure to maintain a safe and clean environment, failure to protect residents from abuse and neglect, and failure to prevent accidents related to wandering residents.
Complaint Details
The complaint investigation revealed failures in notification to POA, environmental safety, resident abuse prevention, and accident prevention. Immediate Jeopardy was identified related to failure to protect a resident expressing suicidal ideation, resulting in a suicide attempt. The facility implemented a Plan of Removal including staff education, resident interviews, and policy enforcement.
Findings
The facility failed to notify the Power of Attorney of a resident injury, maintain a safe and clean environment, provide adequate supervision to prevent abuse and neglect, and implement interventions to prevent wandering residents from entering other residents' rooms, resulting in injuries and immediate jeopardy to resident health and safety.
Deficiencies (4)
Failed to notify the Power of Attorney when a resident sustained an injury after wandering into another resident's room.
Failed to provide a safe, clean, and comfortable environment, including littered cigarette butts, stained floors, broken closet doors, and foul odors in hallways.
Failed to protect a resident from abuse and neglect, including failure to provide line of sight supervision after the resident expressed suicidal ideation and attempted suicide by swallowing razor blades.
Failed to prevent accidents by not implementing interventions to prevent a resident from wandering into other residents' rooms and potentially causing harm.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Brief Interview of Mental Status (BIMS) score: 5
Brief Interview of Mental Status (BIMS) score: 4
Date of Plan of Removal implementation: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSA #2 | Social Services Assistant | Reported resident #1 suicidal ideation and communicated with nursing staff |
| Nurse #4 | Nurse | Witnessed resident #1 swallowing razor blades and called 911 |
| CNA #1 | Certified Nursing Aide | Found resident #2 with scratches and reported incident |
| LPN #1 | Licensed Practical Nurse | Noticed bruising on resident #2 and documented findings |
| RN #1 | Registered Nurse | Interviewed about resident #2 incident and wandering behavior |
| Director of Nursing | Director of Nursing | Acknowledged failures in notification and supervision; involved in Plan of Removal |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, environment, and care quality at Princeton Health & Rehabilitation.
Findings
The facility was found to have multiple deficiencies including unresolved water leaks causing unsafe conditions in the therapy room, a broken closet drawer in a resident's room, cockroach infestation in a resident's CPAP machine, and failure to address significant weight loss in a resident due to lack of nutritional planning.
Deficiencies (4)
Water leaks in the therapy room causing wet floors, missing ceiling tiles, and exposed pipes, posing safety hazards to residents.
Broken and missing drawer face in resident #190's closet making it inoperable.
Cockroaches found inside resident #37's CPAP humidifier tank and room.
Failure to implement a nutritional plan for resident #409 who experienced a 7% weight loss in less than one month.
Report Facts
Weight loss percentage: 7
Repair estimate cost: 5000
Dates of resident weights: Weights recorded on 12/21/23 (112.9 lbs), 12/22/23 (111.5 lbs), 12/25/23 (113.0 lbs), 01/01/24 (111.4 lbs), 01/08/24 (105.0 lbs).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist | Physical Therapist (PT) | Reported ongoing water leaks and safety hazards in therapy room and front desk area. |
| Maintenance Director | Maintenance Director (MD) | Reported attempts to repair leaks and lack of work order for broken drawer. |
| Director of Nursing | Director of Nursing (DON) | Discussed resident #409's weight loss and lack of nutritional plan. |
| Respiratory Therapist #1 | Respiratory Therapist (RT) #1 | Documented roaches in resident #37's CPAP machine. |
| Nurse Unit Manager #1 | Nurse Unit Manager (UM) #1 | Recalled incident of roaches in resident #37's room. |
| RT Supervisor | Respiratory Therapist Supervisor (RTS) | Confirmed replacement of resident #37's CPAP machine due to roaches. |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident safety, care quality, medication management, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including unresolved water leaks causing safety hazards, failure to maintain a homelike environment, inaccurate care plans, improper medication administration and storage, failure to maintain controlled substance records, expired medications and supplies stored with unexpired items, lack of weekly wound assessments, and inadequate infection prevention practices.
Deficiencies (10)
Water leaks in therapy room with exposed pipes and missing ceiling tiles causing safety hazards to residents.
Failure to repair damaged or missing drawer face in resident's room.
Presence of cockroaches inside a resident's CPAP humidifier tank.
Failure to develop and implement an accurate care plan reflecting resident's indwelling catheter use.
Failure to administer medications per physician orders and professional standards, including hiding medications in food without consent.
Failure to maintain accurate controlled substance counts and documentation on medication carts.
Medications not kept in original packaging; presence of pre-poured medications and expired medications stored with unexpired ones.
Failure to dispose of eye drops within 30 days of opening and expired supplies stored with unexpired supplies.
Failure to document weekly wound assessments for a resident with a stage 2 pressure ulcer.
Failure to maintain proper infection prevention measures including safe transport of soiled laundry and use of appropriate PPE by staff.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 261
Expired enoxaparin count: 6
Expiration date: 10
Expiration date: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in medication administration deficiencies for hiding medications in food. |
| Maintenance Director | Named in water leak repair deficiencies. | |
| Physical Therapist | Reported water leak safety hazard and communication with CEO. | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including medication administration, wound care, and infection control. |
| Nurse Unit Manager #1 | Interviewed regarding medication administration and care plan accuracy. | |
| Respiratory Therapist #1 | RT #1 | Documented roaches in resident's CPAP machine. |
| RT Supervisor | Confirmed replacement of CPAP machine due to roaches. | |
| Housekeeper #1 | HK #1 | Observed not wearing full PPE while sorting soiled laundry. |
| President of Clinical Services | VPCS | Confirmed PPE requirements for laundry staff. |
| Certified Nursing Assistant #5 | CNA #5 | Observed improper handling of soiled linens. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide an orderly, homelike environment by leaving unused medical equipment in a resident's room for an extended period.
Complaint Details
The visit was complaint-related, investigating the failure to remove unused medical equipment from Resident #1's room. The complaint was substantiated as staff confirmed no further orders for the equipment and acknowledged it should have been removed.
Findings
The facility failed to remove unused medical equipment from Resident #1's room for 24 days after last use, which could lead to residents feeling disrespected, uncomfortable, and depressed. Interviews and record reviews confirmed the equipment was left unnecessarily and staff acknowledged the oversight.
Deficiencies (1)
Failed to provide an orderly, homelike environment by leaving unused medical equipment in the resident's room for 24 days after last use.
Report Facts
Days unused medical equipment left in room: 24
Residents reviewed for rights: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed no additional orders for sodium chloride and moved equipment to nurse's station. |
| DON | Director of Nursing | Stated expectation that medical equipment should be removed within 3-5 days when no longer in use. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations that the facility failed to honor a resident's right to refuse care and that staff held down the resident's wrists during care, causing bruising.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews that confirmed staff held down the resident's wrists during care despite resistance, causing bruising. The resident and complainants reported the incident, and multiple staff interviews corroborated the findings.
Findings
The facility failed to honor resident rights to refuse care for one resident who was physically restrained by staff during care despite resistance, resulting in bruising on the resident's wrists and arms. Interviews with staff, the resident, and complainants confirmed the resident was held down during care, which caused harm. The facility's approaches to managing resistance were reviewed and found deficient.
Deficiencies (2)
Failed to honor resident's right to refuse care, resulting in physical restraint and bruising.
Failed to protect resident from abuse when staff held down resident's arms during care causing bruising.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #5 | Registered Nurse | Interviewed regarding bruising on resident's wrists and staff response. |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed about rapport with resident and care attempts. |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed about night shift care and resident resistance. |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Primary CNA on night of incident; interviewed about resident resistance and care. |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed about resident refusal and care attempts. |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed about resident refusal and care attempts. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about staff expectations and resident care. |
| Director of Nursing | Director of Nursing | Interviewed about expectations for working with resistant residents. |
| Assistant #1 | Interviewed about CNA re-education and incident details. |
Inspection Report
Routine
Deficiencies: 11
Date: Jan 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, medication administration, resident care, safety, and regulatory requirements.
Findings
The facility failed to ensure proper medication administration, accurate documentation of skin assessments, implementation of care measures to prevent contractures, supervision to prevent accidents, adherence to physician orders, proper labeling and storage of medications, accurate resident records, and adequate staff training. Several residents were affected by these deficiencies.
Deficiencies (11)
Failure to administer and discharge medications as indicated on pharmacist's recommendations and physician's orders for residents #123, #132, and #135.
Failure to accurately document and report skin assessments conducted with refusals and per resident's self-report for resident #132.
Failure to implement and document care measure interventions to prevent contractures for resident #135.
Failure to get resident #135 out of bed and into the wheelchair regularly per physician order and care plan.
Failure to follow physician orders for therapeutic medication levels of an antipsychotic medication for resident #107.
Failure to ensure residents were free from accident hazards and provide adequate supervision to prevent accidents for residents #14, #123, #157, and #77.
Failure to provide appropriate care for resident #77 with Foley catheter re-insertion after removal due to urinary retention.
Significant medication errors including incorrect dosage administration for resident #14, failure to administer medication prior to shower for resident #106, and crushing medication without order for resident #70.
Failure to ensure medications and supplies stored in medication storage rooms and refrigerators were not expired on 300 and 500 units.
Failure to keep accurate, up to date resident records for residents #6, #90, #129, #132, #157, and #167 including missing PASRR Level II screening, inaccurate care plans, inaccurate diagnoses, and missing oncology treatment records.
Failure to ensure Certified Nursing Assistants had required 12 hours of yearly in-service training completed for CNA #10, #11, and #12.
Report Facts
Medication error duration: 5
Urine volume drained: 1800
Missing lab dates: 5
Length of call light cord: 3
Expired medication date: Apr 3, 2022
Expired medication date: Oct 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and lab orders for resident #123 and #107. |
| RN #1 | Registered Nurse | Interviewed regarding skin assessments and documentation for resident #132 and #167. |
| UM #6 | Unit Manager | Interviewed regarding restorative staff duties, medication lab orders, and inaccurate documentation. |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding lab order process and missing lab slips for resident #107. |
| Pharmacist | Facility Pharmacist | Interviewed regarding medication refill errors for resident #14. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate psychiatric diagnoses for residents #90 and #129. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding CNA training compliance. |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding staff training and competencies. |
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