Sandia Ridge Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure the environment was free of accident hazards for 1 (R #1) of 1 (R #1) residents, when the facility staff failed to:Use a Hoyer lift (equipment used to move residents who have limited mobility) and two staff members to safely transfer R #1 as required. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm.

Inspectors wroteBased on observation and interview, the facility failed to provide snacks at night for all residents who wanted an evening snack. This deficient practice is likely to cause resident to be at risk of unnecessary hunger and frustration.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff properly stored and secured medications for all residents residing on the 200, 300, and 400 hallway when medication carts were left unlocked and unattended. This deficient practice is likely that resident have unauthorized access to medications that could result in injury or illness.

Inspectors wroteBased on observation, and interview, the facility failed to protect residents' personal health information (PHI) by leaving a document unattended containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) on top of a nursing cart in hallway. This deficient practice is likely to result in passerby's to have unauthorized access to sensitive information, putting residents' privacy at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the physician orders regarding weight bearing status and isolation needs from the transferring hospital were accurately transferred and implemented for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for admission's orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for baseline care plans. This deficient practice is likely that residents will not receive the appropriate care needed causing harm or worsening of current condition.

Inspectors wroteBased on record review and interview the facility failed to obtain physicians orders for Hospice Services for 1 (R #'s 3) of 3 (R #'s 1, 2, and 3) residents reviewed for Hospice Services. This deficient practice is likely to result in residents not receiving the care need to maintain their optimal health as planned by their medical provider.

Inspectors wroteBased on record review and interview the facility failed to provide showers for1 (R #2) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for Activities of Daily Living (ADL). This deficient practice is likely to result in residents feeling dirty and neglected resulting in isolation.

Inspectors wroteBased on observation, and interviews, the facility failed to store and serve food under sanitary conditions when staff failed to ensure:Food items were labeled and dated. Dietary Aides are preparing food with no beard restraints. These deficient practices are likely to cause foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe, clean, and homelike environment for 4 (Room #'s 210, 305, 307, and 405) out of 4 (Room #'s 210, 305, 307, and 405) resident rooms on the 200, 300, and 400 halls, when: The facility failed to ensure resident restrooms were maintained in good repair (a condition in which something is properly maintained, fully functional, and free from significant defects or damage) and did not have damaged baseboards (a narrow wooden board running along the base of an interior wall). If the facility does not ensure resident restrooms are maintained in good repair, then residents are likely to experience a decreased quality of life, pest infestation, and injury due to unsafe environmental conditions.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment (to prevent the development and transmission of communicable diseases and infections) for 1 (R #1) of 3 (R #1, #2 and #3) residents, when: The facility failed to post the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage for R #1. This deficient practice is likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure meals were palatable and served at an appetizing temperature for 6 (R #1, R #2, R #3, R #4, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed. This failed practice had the potential to affect all 128 residents identified on the resident census list provided by the Administrator on 02/19/26. If meals are not appetizing, then residents may not eat meals and lose weight.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 4 (R #'s 1, 41, 85 and 114) of 4 (R #'s 1, 41, 85 and 114) residents reviewed for ADL care by not: Providing baths/showers per the schedule for R #'s 1, 41, and 85. Providing nail care for R #114. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview the facility failed to protect 1 (R #2) of 1 (R #2) resident reviewed from the use of a physical restraint that was not required to treat a resident's medical condition. This deficient practice could likely result in resident feeling trapped and hopeless.

Inspectors wroteBased on record review and interview the facility failed to revise the care plan for 1 (R #2) of 1 (R #2) resident reviewed for care planning. This deficient practice has the potential for staff to fail to identify resident as an elopement risk.

Inspectors wroteBased on record review and interview the facility failed to ensure staff provided care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident. Nursing staff failed to maintain the scene of a suspcious death before calling the New Mexico Office of Medical Investigator. (OMI) (a New Mexico state agency that reviews and determines the need for investigation and autopsy when a person dies in a facility). This deficient practice could disturb the scene of a suspicious death so that it cannot be thoroughly assessed and reviewed by proper authorities.

Inspectors wroteBased on observation record review and interview, the facility failed to provide adequate supervision for 1 (R #2) of 1 (R #2) resident reviewed who were identified as a risk for elopement (leave facility without authorization or supervision potentially endangering themselves or others.) This deficient practice likely resulted in the resident being able to eloped from the facility for over 24 hours likely putting himself at serious risk of adverse outcomes.

Inspectors wroteBased on record review and interview the facility failed to ensure that 1 (R #1) of 1 (R #1) resident received prescribed intravenous (IV) (medications administered directly into the vein) medications on time in accordance with professional standards of practice. The facility failed to provide and administer antibiotic (antibacterial) medications as ordered by the prescriber.

Inspectors wroteBased on record review and interview, the facility failed to ensure that resident injuries of unknown sources were reported to the State Agency within 24 hours to the state agency for 1 (R #4) of 2 (R #4 and R #5) residents reviewed. If the facility is not immediately investigating and reporting injuries of unknown sources residents are likely to be at risk of further injuries.

Inspectors wroteBased on record review and interview, the facility failed to investigate and report within five working days, injuries of unknown origin for 1 (R #4) of 2 (R #4 and R #5) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview the facility failed to keep residents free from abuse for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for abuse and neglect. This deficient practice likely resulted in staff to resident abuse in which R #1 had bruises to both hands.

Inspectors wroteBased on observation, record review, and interview, the facility failed to document the daily temperature of a resident refrigerator used to store resident snacks that was located in the 100 unit of the facility. This deficient practice is likely to affect all 23 residents of the 100 unit as listed on the resident census list provided by the administrator on 07/23/24 and could likely lead to foods not being stored properly.

Inspectors wroteBased on record review and interview, the facility failed to recognize, investigate, and respond to the grievance of 1 (R #1) of 5 (R #1, #2, #3, #4, and #5) residents. This deficient practice is likely to result in residents feeling that their concerns do not matter, and their rights are not being honored.

Inspectors wroteBased on observation and interview, the facility failed to maintain proper food temperatures for all 126 residents listed on the census as provided by the facility Director of Nursing on 11/27/23. This deficient practice could likely result in bacterial growth and foodborne illness.

Inspectors wroteThis is a past noncompliance deficiency. Based on record review and interview, the facility failed to initiate treatment of a pressure wound for 1 ( R#1) of 6 (R #1, R #4, R #6, R #7, R #8, and R #9) residents reviewed for wound care. This deficient practice could likely result in residents not receiving wound care in a timely manner after a wound has been identified.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to immediately notify/report to the physician a change of condition for two residents (Resident (R)75 and R53) out of 28 sampled residents. The facility's failed practice likely resulted in R75's death at the facility on [DATE].

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure residents were protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and failed to have evidence that all alleged violations were thoroughly investigated for one resident (Resident (R) 25) out of one resident reviewed for abuse in a total sample of 28 residents. Specifically, the two alleged perpetrators, Certified Nursing Assistant (CNA)1 and CNA2 were not removed from the facility but were reassigned and remained in the facility working with other residents the evening of the alleged abuse and the Administrator failed to thoroughly investigate conflicting verbal and written statements by the CNAs. This deficient practice could likely result in residents being at risk of abuse.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to complete a change of condition assessment when the nursing staff had difficulty arousing with a sternal rub (A sternal rub is the application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimulit) through the night and into the next day for one resident (Resident (R) 75) out of a total sample of 28 residents. The facility's failed practice likely resulted in R75's death at the facility on [DATE].

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure an individualized program of activities was implemented for one of one resident (Resident (R) 38) reviewed for activities out of a total sample of 28 residents. This failure had the potential to cause boredom and isolation for R38.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to provide a meal to cover the lunch hour dialysis treatment three days a week for one of one resident (Resident (R)86) reviewed for dialysis out of a total sample of 28 residents. This failure had the potential to create altered nutritional status and weight loss for R86.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to administer oxycodone as ordered by the physician and requested by the resident for one resident (Resident (R)236) of one resident reviewed for pain management in a total sample of 28 residents. This failure increased the potential for R236 to have unrelieved pain.

Inspectors wroteBased on interviews, observations, and review of records, the facility failed to ensure the staff were competent with skills and knowledge to provide care for one of one resident (Resident (R) 236) reviewed for care of a chest tube out of a total sample of 28 residents. The facility's deficient practice likely resulted in the chest tube being blocked and unable to be removed.

Inspectors wroteBased on record review and interviews, the facility failed to administer antibiotic medication as ordered for to two of two residents (Resident (R) 234 and R230) reviewed for antibiotic use in a total sample of 28 residents. This failure could likely increase the risk of ineffective treatment for infection resulting in worsening infection.

Inspectors wroteBased on record review, and interview the facility failed to prevent resident to resident abuse for 2 [R #16 and 224] of 5 [R #s 16, 42, 60, 224 and 265] residents reviewed for abuse and neglect by not providing enough supervision for a resident with known sexually inappropriate behaviors and not implementing additional interventions to protect residents. This deficient practice likely resulted in psychosocial harm to residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a sufficient amount of nursing staff to meet the needs of 5 (R #14, 16, 115, 224 and 271) of 5 (R #14, 16, 115, 224 and 271) resident reviewed for ADLs (Activities of Daily Living) and abuse by not having enough licensed nursing staff and Certified Nursing Assistants (CNA's) to: 1. Provide showers per resident preference and need. 2. Provide required supervision on the secured unit needed to prevent resident to resident sexual abuse. This deficient practice could likely resulted in residents not receiving their required care and likely resulted in psychosocial harm on the secured unit.

Inspectors wroteBased on record review and interview the facility failed to ensure that an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for 3 [R #'s 39, 58, and 471] of 5 [R #'s 24, 39, 58, 90, 471] residents' electronic records: 1. Had accurate Advance Directive wishes information on file and in different areas in the resident electronic record that was conflicting and 2. Did not complete an Advanced Directive in a timely manner. This deficient practice could likely cause confusion with the residents advance directives and can likely result in the end of life wishes not being met.

Inspectors wroteBased on record review and interview, the facility failed to create a baseline care plan for 1 (R #78) of 2 (R #s 44 and 78) residents sampled for baseline care plans completed within 48 hours of admission. If the facility fails to include care, treatment, services, and goals the residents may not receive the appropriate care. This deficient practice could potentially result in residents not being able to achieve their highest practical abilities, could result in a decline, and staff not being aware of the residents needed care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that bathing/showering assistance was provided for 3 (R #14, 115, and 271) of 3 (R #14, 115, and 271) residents reviewed for ADLs (activities of daily living). This deficient practice could likely result in residents in need of this specialized care to experience a decline in their ability to perform hygiene tasks and/or maintain good personal hygiene.

Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing activity program for all 24 residents on the secure unit [is defined as a special care unit in a designated, separate area for individuals with Alzheimer's disease or dementia that is locked, or secured to prevent or limit access by a resident outside the designated or separated area] that were identified on the resident census that the facility Center Executive Director provided on 10/18/21. If the facility is not ensuring that all residents are receiving an ongoing activity program, documenting resident refusals and making in room activity accommodations, then residents are likely to experience increased feelings of isolation [social separation from others] and depression [feelings of sadness or loss of interest in doing activities].

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident with a diagnosis of diabetes mellitus (a disease of impaired glucose metabolism) was offered foods to help maintain a healthy blood glucose level for 1 [R #17] of 6 [R #s 17, 44, 58, 67, 223, 272] residents reviewed for nutrition. This deficient practice has the potential to result in dangerously high blood glucose levels in a diabetic resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff members follow their established scope of practice (the services that a qualified health professional is deemed competent to perform, and permitted to undertake in keeping with the terms of their professional license) for all the residents residing on the 200 hall on 10/24/21 by allowing an uncertified staff member to administer medications without the supervision of a licensed nurse. This deficient practice is likely to allow the opportunity for a medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medically-related social services were provided for 1 [R #265] of 1 [R #265] mentally incompetent residents that were identified as needing assistance in obtaining health care agents [such as a Power of Attorney [POA] or a Guardian [a trusted person appointed legally to to make medical decisions on the residents behalf]. This deficient practice could lead to the residents receiving inconsistent services and not having their best interests served within the facility.

Inspectors wroteBased on interview and record review, the facility failed to address and respond to the resident concerns and grievances (an official statement of a complaint over something believed to be wrong or unfair) for 1 (R #421) of 3 (R #24, 90 and 421) residents. This deficient practice could likely result in residents feeling that their issues or concerns are not taken seriously, leading to feelings of helplessness, and frustration.

Inspectors wroteBased on record review and interview, the facility failed to accurately assess dialysis (medical treatment that filters and purifies the blood using a machine when your kidneys do not function correctly) needs for 1 (R #78) of 2 (R #s 44 and 78) residents sampled for Dialysis needs. The deficient practice could likely to result in residents not receiving needed care and treatment.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement (put into place) a comprehensive person-centered care plan for 1 (R #67) of 3 (R #s 44, 67 and 78) residents reviewed for care plans. Failure to develop and implement a resident centered care plan is likely to result in staff's failure to understand and implement the needs and treatments of residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that care plans had been revised, updated, and reflected up-to-date goals, and interventions for 1 [R #42] of 3 [R # 16, 42 and 97] residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care and assistance they need to maintain their highest practicable well being.

Inspectors wroteBased on interview and record review the facility failed to ensure that 1 (R #278) of 1 (R #278) resident with a gastronomy tube (G-Tube- a tube inserted through the abdomen that delivers nutrition directly to the stomach) received continuous (24-hour) nutrition feed as prescribed by a physician to commence (start) the day resident was admitted into the facility. This deficient practice could likely cause R #278 to be starved of food and become dehydrated (harmful reduction in the amount of water in the body) from lack of fluids/water due to the facility's delay in administering (giving)/initiating (beginning) nutritional feed delivery.

Inspectors wroteBased on record review and interview the facility failed to ensure that 1 [R #97] of 7 [R #'s 4, 45, 58, 66, 68, 87, and 97] residents reviewed for psychotropic medications (medications used to treat psychiatric conditions by altering perception, mood, consciousness, cognition or behavior) were not given medications longer than necessary. This deficient practice could likely result in residents continuing to receive medications that are inappropriate for use in the elderly population due to having a high mortality [state of being subjected to death] rate.

Inspectors wroteOn 10/19/20 at 9:20 am, observations were made of R #8 being served diced (not pureed) potatoes for breakfast, at 1:10 pm during the lunch meal R #8 was observed to have received a chicken sandwich and hash browns (not pureed). R #8's roommate R #110 notified staff that she [R #8] did not get the proper meal texture for lunch. R #8 is not able to advocate for herself and likely would have eaten the non-pureed meal that was delivered to her if the roommate had not intervened. On 10/19/20 at 1:10 pm, observations of the lunch meal were being made. Conversations between the Dietary Aides indicated that there were issues with getting lunch out timely today. There had also been issues with the breakfast meal [some residents receiving an inadequate meal]. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that residents were bathed according to the facility schedule and their preferences for 2 (R #38 and 93) of 3 (R #21, 38, and 93) resident reviewed for choices. This deficient practice has the potential to prevent residents from maintaining personal hygiene per their personal preference.

Inspectors wroteBased on record review and interview the facility failed to ensure that for 4 (R #s 67, 106, 178 and 179) of 10 (R #s 19, 67, 73, 76, 84, 89, 106, 178, 179,and 183) new and re-admitted residents whose records were reviewed for Advance Directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) were filled out and updated timely. This deficient practice could cause confusion with the residents' advance directives resulting in the end of life wishes not being met.

Inspectors wroteBased on interview and record review the facility failed to ensure the assistance needed for 2 (R #8 and R #103) of 2 (R #8 and R #103) residents reviewed for receiving restorative nursing services, [Restorative nursing programs aim is to keep residents from declining once rehabilitation therapy {such as physical therapy (PT), occupational therapy (OT) and speech therapy (ST)} has ended, a program provides a wide range of services to augment residents strengths and prevent declines if possible] was provided. This deficient practice could likely affect any of the 22 residents noted to have restorative nursing needs, from list provided by the Center Nurse Executive on 10/21/20. If an organized and supervised program is not in place it will likely result in residents affected not gaining or maintaining their optimal state of well-being while living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a substantive program of activities for 4 [R # 18, 41, 66, and 93] out of 4 [R # 18, 41, 66, and 93] residents looked at for activities. Some residents stated that they were bored and depressed and don't have enough to do. This deficient practice has the potential to diminish residents' quality of life through lack of engagement, lack of socialization, and boredom.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for 2 (R #s 40 and 111) of 2 (R #s 40 and 111) residents reviewed for medications not given as ordered by the physician. This deficient practice is likely to result in a resident failing to obtain maximum wellness and/or suffering prolonged illness.

Inspectors wroteBased on observation, record review and interview the facility failed to: 1. Communicate and maintain menu options 2. Update resident preferences for 7 (R#'s 41, 96, 103, 111, 120, 324, and 325) of 7 (R#'s 41, 96, 103, 111, 120, 324, and 325) residents reviewed during dining observations. This deficienct practice could likely result in a decline in the psychosocial health of the residents as the residents develop feelings of frustration, anxiety, and disappointment.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that meals were served at an appetizing temperature and palatable, for 10 (R # 15, 18, 38, 41, 50, 55, 91,103, 120, and 325) of 10 (R # 15, 18, 38, 41, 50, 55, 91,103, 120, and 325 ) residents reviewed for meal quality. This deficient practice reduces residents' ability to make choices about important aspects of their lives and may decrease their quality of life by not having nutritious palatable food and food served at the proper temperature.

Inspectors wroteBased on observation and interview the facility failed to implement all recommended transmission-based precautions for residents newly admitted and readmitted to the facility. While caring for residents suspected of having COVID-19 [is a new illness that can affect your lungs and airways. It's caused by a virus called coronavirus] during the 2020 public health emergency, these failed practices put all 128 residents in the facility at increased risk for infection with COVID-19. On the date of this survey, 10/19/20, recommended /nationally recognized transmission-based precautions included staff caring for residents newly admitted or readmitted to wear gowns, gloves, an N95 face mask (or higher-level protection) and goggles or face shield and for residents to be placed in a private room (if available) with the door closed for 14 days. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that medications were stored safely, which has the potential to affect any of the facility's 22 residents listed on the facility census as living on the 200 unit provided by the Administrator on [DATE]. Un-labeled, altered labeled and medications labeled for residents that no longer on the unit/in the facility were stored with current residents medications. Medications were left in an unlocked unattended treatment cart on a behavioral health care unit. These deficient practices have the potential to result in resident injury, through use of expired product, potentially contaminated product, or self administration of medication by a confused resident.