Inspection Reports for
Rio Rancho Center

The facility failed to ensure staff consistently used gowns and gloves as part of enhanced barrier precautions for a resident with multiple wounds, increasing the risk of transmission of infectious organisms. Staff interviews and observations confirmed inconsistent compliance with the infection control policy.

The complaint investigation found that the facility did not create a complete baseline care plan for resident #3 within 48 hours of admission despite the resident's high fall risk and complex medical conditions. The resident fell on 05/11/25 and was hospitalized. Interviews with the resident's son, Unit Manager, Administrator, and Director of Nursing confirmed the failure to develop the care plan and address fall risk interventions.

The facility failed to create a complete baseline care plan for resident #3 within 48 hours of admission, omitting key elements such as physician orders, dietary orders, therapy services, social services, and fall prevention interventions. The resident experienced a fall on 05/11/25, and the care plan was not revised accordingly. Interviews with staff and family confirmed the lack of a complete care plan despite the resident's high fall risk.

The facility was found deficient in multiple areas including failure to honor resident preferences for showers and bed height, inadequate safeguarding of resident health information, failure to investigate abuse allegations, insufficient discharge planning, incomplete care plans, lack of physician orders for hospice care, inadequate treatment and care for residents, failure to prevent falls, improper respiratory care, incomplete pharmacist drug regimen reviews, medication administration errors, improper medication storage, serving food at improper temperatures, failure to accommodate food preferences, incomplete medical records, lack of hospice coordination, and insufficient nurse aide training.

The visit was complaint-related, focusing on issues with MDS assessment accuracy, bathing/showering assistance, and meal service timeliness. The deficiencies were substantiated based on record reviews, observations, and interviews.

The facility failed to ensure accurate MDS assessments for a resident admitted without a catheter but documented as having one, failed to provide scheduled bathing/showering assistance to a resident, and failed to serve meals timely according to the facility's meal schedule, resulting in residents receiving meals late or sometimes not at all.

The facility failed to maintain accurate weights for one resident out of three sampled, potentially affecting nutrition assessment. Additionally, the facility did not have a Registered Nurse on duty for at least 8 hours during each 24-hour period on multiple days across several months, affecting all 114 residents.

The complaint investigation found substantiated deficiencies related to insufficient staffing leading to missed resident care such as baths/showers and delayed call light responses. Residents and staff interviews confirmed these issues.

The facility failed to provide adequate nursing staff to meet the needs of 113 residents, resulting in missed scheduled baths/showers and delayed responses to call lights. Multiple residents confirmed they were not offered the expected frequency of baths or showers, and staff interviews corroborated staffing shortages impacting care delivery.

The facility was found deficient in multiple areas including failure to provide adequate communication services for non-English speaking residents, missed medical appointments due to transportation issues, failure to provide showers and personal care as scheduled, incomplete care plan meetings, improper medication management and administration, inadequate infection control practices, failure to provide meals according to dietary orders, and insufficient staffing impacting resident care and timely response to call lights.

The facility was found deficient in multiple areas including failure to consistently honor resident shower preferences, improper and undocumented resident discharges, incomplete discharge planning documentation, failure to provide adequate ADL assistance with baths/showers, and medication administration errors involving late administration of medications and insulin.

The complaint investigation substantiated that the facility failed to notify providers and family about resident #1's change in condition leading to severe dehydration. It also found the facility discharged resident #9 improperly on the same day as the Notice of Medicare Non-Coverage issuance. Additionally, the facility failed to provide adequate care and documentation for residents #1, #4, and #10, resulting in immediate jeopardy.

The facility failed to notify providers and family of a resident's significant change in condition leading to severe dehydration requiring emergency care. The facility also failed to honor residents' rights by discharging a resident the same day a Notice of Medicare Non-Coverage was issued. Additionally, the facility failed to ensure residents received appropriate assistance with activities of daily living (ADLs) and proper documentation of care, resulting in immediate jeopardy findings.

The complaint investigation substantiated physical abuse of Resident 80 by a staff member. The facility failed to timely report the abuse to law enforcement and the licensing board and did not conduct a thorough investigation with adequate documentation or witness interviews. Similar failures in reporting and investigation were noted for residents 31 and 12. The facility also failed to submit timely five-day follow-up reports to the State Survey Agency for abuse incidents.

The facility was found to have substantiated abuse of a resident by a staff member, failures in timely and thorough abuse reporting and investigation, inadequate discharge planning for a resident desiring community reintegration, insufficient individualized activities for a resident, inadequate supervision and safety measures leading to resident injuries, failure to promote continence and toileting assistance, lack of monitoring target behaviors for antipsychotic medication use, unsecured medication carts, failure to provide dental care follow-up, and improper food storage temperatures in the nourishment refrigerator.