Deficiencies (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
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding misappropriation of resident property and medication errors at The Rehabilitation Center of Albuquerque.
Complaint Details
The complaint involved misappropriation of resident property by a transport driver who took $100 from a resident and a medication error where a resident received a duplicate dose of medication. The transport driver was placed on administrative leave and terminated. The facility reimbursed the resident for the $100. The medication error was not reported to the State Agency, limiting regulatory oversight.
Findings
The facility was found deficient for failing to protect residents from misappropriation of property by a transport driver, failing to report a medication error to the State Agency, administering a duplicate dose of medication to a resident, and failing to secure medication carts properly.
Deficiencies (4)
Failed to protect resident from wrongful use of belongings or money by a transport driver who took $100 from a resident.
Failed to report a medication error involving a resident to the State Agency as required.
Failed to prevent a significant medication error when staff administered a second dose of Mounjaro within 24 hours to a resident.
Failed to ensure medications were stored securely when a medication cart remained unlocked and unattended.
Report Facts
Drivers trained on Code of Conduct: 14
Amount of money misappropriated: 100
Duplicate medication dose: 2
Blood glucose monitoring frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Noted medication storage issue and described medication error circumstances. |
| RN #5 | Registered Nurse | Left medication cart unlocked, allowing potential unauthorized access. |
| Administrator | Interviewed regarding misappropriation incident and medication error reporting. | |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed about medication error and medication cart security. |
| Charge Nurse | Charge Nurse | Interviewed about medication error related to nurse not reading medication label carefully. |
| Medical Director | Medical Director | Interviewed about significance of medication error and reporting requirements. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to honor a resident's Advance Directives, specifically a Do Not Resuscitate (DNR) order, when staff provided cardiopulmonary resuscitation (CPR) to the resident.
Complaint Details
The complaint investigation found that staff provided CPR to a resident with a documented Do Not Resuscitate (DNR) order, violating the resident's advance directive. The facility was notified of Immediate Jeopardy, which was later removed after corrective actions including audits of code status orders, staff training on MOST form accuracy, and policy updates.
Findings
The facility failed to ensure that a resident's DNR status was honored during an emergency, resulting in CPR being administered contrary to the resident's wishes. Immediate Jeopardy was identified but later removed after corrective actions including audits, staff education, and policy reviews were implemented.
Deficiencies (1)
Failure to honor a resident's right to request, refuse, and/or discontinue treatment, including participation in experimental research and formulation of an advance directive.
Report Facts
Residents affected: 1
Time resident pronounced dead: 2.25
Time CPR started: 2.05
Duration of Immediate Jeopardy monitoring: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Interviewed regarding awareness of incident and staff training |
| Director of Nursing | Director of Nursing | Interviewed about facility code status policy and staff training |
| Registered Nurse #5 | Registered Nurse | Provided information about staff training on MOST form accuracy |
| Registered Nurse #6 | Registered Nurse | Interviewed about MOST form procedures and code status verification |
| Registered Nurse #7 | Registered Nurse | Described training on MOST forms and code status documentation |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Described instructions on obtaining resident code status |
| Registered Nurse #3 | Registered Nurse | Described staff training on resident code status and communication with POA |
Inspection Report
Routine
Deficiencies: 9
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care planning, medication management, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights regarding personal property, failure to honor advance directives, incomplete baseline care plans, unsecured treatment and medication carts, inappropriate catheter care, medication errors including delayed administration of anticoagulants and antipsychotics, improper insulin pen handling, malfunctioning dishwasher sanitation, and call light accessibility.
Deficiencies (9)
Failed to ensure a resident's right to retain personal property when staff removed Christmas lights and did not put them back after safety approval.
Failed to honor a resident's Do Not Resuscitate (DNR) advance directive when CPR was provided.
Failed to create accurate baseline care plans within 48 hours of admission for two residents.
Failed to lock treatment carts on 400 and 100 units when unattended, risking resident access to medical supplies.
Failed to provide appropriate care for residents with urinary retention and indwelling catheters, including lack of urology follow-up and documentation.
Failed to ensure timely administration of prescribed anticoagulant (warfarin) and antipsychotic medication (Aristada), risking resident health.
Failed to date and discard opened insulin pens within 28 days and failed to secure medication and treatment carts properly.
Failed to ensure the low temperature dishwasher sanitized dishes properly and repaired it timely.
Failed to ensure call lights were within reach for residents in their rooms.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 60
Residents affected: 116
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #4 | Called On-Call Provider regarding medication reconciliation for resident #69 | |
| Nurse #3 | Interviewed about insulin pen dating and discarding | |
| Licensed Practical Nurse #1 | Confirmed respiratory treatment carts unlocked and explained practice | |
| Respiratory Therapist #1 | Stated expectation for respiratory carts to be locked | |
| Registered Nurse #1 | Responsible for medication cart on 100 hall and stated it should be locked | |
| Nurse Practitioner (NP) | Discussed failure to honor DNR and antipsychotic medication administration | |
| Director of Nursing (DON) | Provided multiple interviews regarding care planning, medication errors, and cart locking | |
| Consultant Pharmacist | Provided recommendations on warfarin and insulin pen handling | |
| Kitchen Manager (KM) | Discussed dishwasher malfunction and staff instructions | |
| Certified Nursing Assistant (CNA) #8 | Observed leaving call lights on floor |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 21, 2025
Visit Reason
The inspection was conducted to assess the safety, functionality, sanitation, and comfort of the nursing home environment, specifically regarding a broken wall inside a resident's room that had not been reported or repaired.
Findings
The facility failed to provide a safe and comfortable environment for one resident due to a broken wall in the resident's room that was not reported or repaired, creating risks for mold, mildew growth, and potential entry of mice which could cause damage and spread diseases.
Deficiencies (1)
Facility failed to report or repair a broken wall inside resident #1's room, leading to potential mold growth and risk of mice entering.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid #1 | Certified Nurse Aid (CNA) | Interviewed and stated unawareness of the broken wall and willingness to report if known |
| Maintenance Director | Maintenance Director | Interviewed and stated unawareness of the broken wall and explained expected reporting process |
| Director of Nursing | Director of Nursing (DON) | Interviewed and stated expectation that nurses and CNAs report maintenance issues |
| Administrator | Administrator | Interviewed and stated expectations for staff reporting and quality of life rounds |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding medication administration practices for a resident with a gastrostomy tube (g-tube).
Complaint Details
The complaint was substantiated based on record review, video evidence, and staff interview showing improper medication administration practices by RN #1 for resident #1.
Findings
The facility failed to follow a physician's order and professional standards for medication administration via g-tube for one resident, resulting in multiple medications being administered simultaneously without flushing the tube as ordered, which could cause tube clogging or medication incompatibility.
Deficiencies (1)
Failure to follow physician's order and professional standards for medication administration via g-tube, including not flushing the tube before, between, and after medications and administering multiple medications simultaneously.
Report Facts
Medication doses administered simultaneously: 3
Flushing volume ordered: 30
Flushing volume ordered between medications: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration deficiency for not following orders regarding g-tube medication administration. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and confirmed RN #1 did not follow orders. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 29, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of missed seizure medications, inadequate support for activities of daily living including shower schedules and call light response times, improper respiratory care, significant medication errors, and poor meal quality.
Complaint Details
The complaint investigation revealed failure to notify the physician about missed seizure medications for resident #68, resulting in breakthrough seizures and hospital transfer. Additional complaints included inadequate shower schedules and call light response times for residents #2, #73, and #309, improper respiratory care for resident #309, medication errors for resident #68, and poor meal quality affecting multiple residents.
Findings
The facility failed to notify the physician about missed seizure medications for one resident, resulting in breakthrough seizures and hospital transfer. The facility also failed to consistently offer showers and timely call light responses to several residents, failed to maintain proper oxygen therapy orders and equipment labeling for one resident, had significant medication errors related to missed doses of anti-seizure medication, and served meals that were often cold, unappetizing, and sometimes unsafe.
Deficiencies (5)
Failed to notify physician of missed seizure medications for resident #68, resulting in delayed treatment and breakthrough seizures.
Failed to support residents in activities of daily living by not offering showers as scheduled and not answering call lights timely for residents #2, #73, and #309.
Failed to ensure physician orders for oxygen therapy and proper labeling of oxygen tubing and humidifier for resident #309.
Failed to keep resident #68 free from significant medication errors by missing doses of levetiracetam, resulting in adverse effects.
Failed to ensure meals were palatable, attractive, and served at safe and appetizing temperatures for multiple residents.
Report Facts
Missed medication doses: 3
Residents affected: 6
Call light wait time: 22
BIMS scores: 14
BIMS scores: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed medication availability issues, failure to notify provider, shower schedules, call light response expectations, and oxygen therapy orders. |
| Nursing Provider #1 | Nursing Provider (NP) | Stated oxygen tubing and humidifiers should be labeled with date of last change. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Observed resident #73's call light response delay and stated resident required incontinence care. |
| Social Services Director | Social Services Director (SSD) | Conducted interviews regarding medication concerns. |
| Nursing Practice Educator | Nursing Practice Educator (NPE) | Re-educated nurses and CNAs on medication ordering and escalation processes. |
| Dietary Manager | Dietary Manager (DM) | Reported resident complaints about food cart delays causing cold food. |
Inspection Report
Routine
Deficiencies: 8
Date: Mar 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food service, call system functionality, and other facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments regarding insulin use, failure to support residents in activities of daily living such as showering and timely call light response, inadequate respiratory care documentation, improper medication storage, failure to follow posted menus and accommodate dietary preferences, serving food at unsafe temperatures, and a non-functioning call light system for a resident.
Deficiencies (8)
Minimum Data Set assessments included inaccurate insulin use information for 2 residents.
Failed to support residents in activities of daily living by not offering showers as scheduled and not answering call lights timely for 3 residents.
Failed to provide safe and appropriate respiratory care for 1 resident by lacking physician orders for oxygen therapy and unlabeled oxygen tubing.
Failed to properly store medications in medication carts by allowing loose medications under medication cards.
Failed to serve food according to the posted menu and accommodate dietary preferences for multiple residents.
Failed to ensure food was palatable, attractive, and served at safe temperatures; multiple residents reported cold or unappetizing food.
Failed to procure and serve food under sanitary conditions by not monitoring internal food temperatures adequately.
Failed to ensure a resident's call light was functioning as intended, preventing the resident from notifying staff when assistance was needed.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 116
Residents affected: 6
Residents affected: 2
Residents affected: 115
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding shower schedules, call light response times, oxygen therapy orders, medication storage, and call light repair |
| Nursing Provider #1 | Nursing Provider (NP) | Interviewed regarding oxygen tubing labeling |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Interviewed regarding call light response and incontinence care |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding menu substitutions, food temperature complaints, and resident dietary preferences |
| Administrator | Administrator | Interviewed regarding call light repair process |
Inspection Report
Deficiencies: 10
Date: Dec 15, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had accessible emergency call devices, failure to timely report and investigate incidents, inadequate care planning and implementation, failure to provide appropriate treatment and care according to orders, inadequate supervision to prevent accidents, failure to maintain emergency tracheostomy supplies and staff training, failure to follow menu and diet orders, failure to provide food accommodating allergies and preferences, failure to maintain infection prevention and control measures leading to a COVID-19 outbreak, and failure to maintain working call systems in resident bathrooms.
Deficiencies (10)
Failure to ensure two residents had emergency calling devices accessible while in their beds.
Failure to timely report suspected abuse, neglect, or injury and failure to investigate incidents.
Failure to develop and implement complete care plans meeting residents' needs including nutritional monitoring and respiratory device use.
Failure to provide appropriate treatment and care according to physician orders, including notification of elevated blood sugars.
Failure to ensure adequate supervision and assistive devices to prevent falls and accidents.
Failure to ensure residents with tracheostomies had necessary emergency supplies at bedside and staff were trained on emergency tracheostomy care, resulting in immediate jeopardy that was later removed.
Failure to ensure menus met nutritional needs and were followed regarding portion sizes.
Failure to provide food according to diet orders accommodating allergies, intolerances, and preferences.
Failure to implement an infection prevention and control program to prevent spread of COVID-19, resulting in an outbreak affecting 36 residents.
Failure to ensure a working call system was available in resident bathrooms, with a call light inoperable for at least two months.
Report Facts
Residents with COVID-19 outbreak: 36
Residents hospitalized due to COVID-19: 3
Residents reviewed for tracheostomy care: 6
Residents sampled: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in failure to report and investigate resident injury |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including call light accessibility, incident reporting, tracheostomy care, and infection control |
| RNA1 | Registered Nurse Agency | Interviewed regarding tracheostomy care and emergency supplies |
| RTD | Respiratory Therapy Director | Interviewed regarding tracheostomy emergency supplies and staff training |
| CNA1 | Certified Nurse Aide | Observed and interviewed regarding infection control and call light issues |
| CNA6 | Certified Nurse Aide | Interviewed regarding call light and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding diet order compliance and food service |
| Regional Nurse | Regional Nurse | Notified of immediate jeopardy and involved in removal plan |
| Administrator | Administrator | Notified of immediate jeopardy and involved in removal plan |
| Medical Director | Medical Director | Interviewed regarding COVID-19 treatment involvement |
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