The Rehabilitation Center of Albuquerque

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) for 4 (R #'s 5, 6, 7, and 8) of 4 (R #'s 5, 6, 7, and 8) residents reviewed for ADL care provided to dependent residents, when staff failed to: Provide baths/showers per the facility bathing schedule. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 89 residents residing in the facility, when:The facility failed to offer baths or showers to residents as scheduled. The facility staff used R #4's family member to assist with a transfer using a Hoyer lift (equipment used to move residents who have limited mobility) when staff were not available. These deficient practices are likely to negatively impact resident safety, comfort, and impede processes such as timely showers and appropriate assistance with care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident property was protected from misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for 1 (R #3) of 1 (R #3) resident reviewed for misappropriation of resident funds and belongings, when: R #3's purse, wallet, and reading glasses went missing in an area where a facility housekeeper was working, and only R #3's purse was eventually returned to her. If the facility fails to ensure resident property is protected from misappropriation, then residents are at risk for unauthorized use of personal funds, financial exploitation, and potential financial loss.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff revised the care plan for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed, when staff failed to: Conduct a quarterly care plan meeting as required for R #1 in accordance with their admission date and Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff). This deficient practice is likely to result in residents' care and needs not being addressed if care plan meetings are not completed as required.

Inspectors wroteCross-Reference with F0602. Based on record review and interviews, it was determined the facility was not administered in a manner that ensured the effective and efficient use of resources to attain or maintain each resident's highest practicable physical, mental, and psychosocial well being, when:The facility administration failed to prevent unauthorized individuals, who were not contracted or directly hired by the facility, from working in the facility near residents. This deficient practice is likely to affect the 89 residents listed on the facility census provided by the Administrator on 05/13/26. If the facility is unaware of an individuals' status when they enter the facility and are near residents, residents' safety and well being are placed at risk. The finds are: A. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify resident Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care)/emergency contacts and facility providers (Physicians and Nurse Practitioners) of when a resident had a change in condition (a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) for 2 (R #15 and R #25) of 4 (R #15, #16, #17 and #25) residents reviewed, when staff failed to: Notify R #15's emergency contacts regarding illness, falls, and abnormal vital signs (body temperature, pulse rate, rate of breathing, oxygen saturation, and blood pressure). Notify a provider regarding R #25's unresponsive state. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 2 (R #3 and #17) of 2 (R #3 and #17) residents reviewed when staff failed to: Ensure oxygen (O2) was administered per physician orders for R #3. Follow physician orders to obtain STAT (immediately, without delay) laboratory values (numerical measurements from blood, urine, or other bodily fluids that indicate your body's health status, organ function, and potential disease states) and a STAT X-ray (a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-rays being passed through it and being absorbed to different degrees by different materials) for R #17. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) for 1 (R #1) of 1 (R #1) resident reviewed when the facility failed to: Provide surgical wound care per physician orders for R #1. If wound care is not being provided as ordered by a physician, then residents are likely at risk of wound deterioration, infection, delayed healing, and other complications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff properly stored and secured medications and medical supplies for all residents residing on the 300 unit when: The unit treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) was not secured and left unattended. The unit medication cart (a mobile storage unit equipped with drawers and locking mechanisms to hold medications) was not secured and left unattended. If the facility fails to secure medication and treatment carts, then residents are likely to experience unauthorized access to medications and medical supplies, potentially resulting in injury or illness.

Inspectors wroteBased on a record review and interviews, the facility failed to ensure medical records were complete for 2 (R #'s 1 and 25) of 2 (R #'s 1 and 25) residents reviewed when the facility: Documented R #1's surgical wound care treatment in R #1's Electronic Health Record (EHR) as completed, when the wound care treatment was not completed per physician orders. Failed to document R #25's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) in R #25's EHR after R #25 experienced a change in condition (CIC; any noticeable deviation from a person's normal health baseline, whether it is an improvement or a decline in physical, functional, or mental state). [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #17) of 1 (R #17) residents reviewed for baseline care plans, when: R #17's baseline care plan was incomplete and inaccurate due to the baseline care plan failing to include multiple diagnoses with interventions for R #17. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care).

Inspectors wrotePAST NON-COMPLIANCEBased on record review and interviews, the facility failed to ensure residents were free from misappropriation of property for 1 (R #2) of 1 (R #2) resident reviewed, when a transport driver took money from a resident. This deficient practice could result in financial loss, emotional distress, and compromise of resident trust and safety.

Inspectors wroteBased on record review and interview, the facility failed to report a medication error involving 1 (R #1) of 1 (R #1) to the State Agency as required. This failure limited regulatory oversight and placed the residents at risk for serious harm by delaying external review and corrective action. If a facility fails to report medication errors in accordance with abuse prevention and reporting requirements, then the facility limits the State Agency's ability to ensure resident safety, increasing the risk of unaddressed harm and repeated incidents.

Inspectors wroteBased on record review and interviews, the facility failed to prevent a significant medication error when staff administered a second dose of Mounjaro (GLP-1 Trizepatide) 12.5 milligrams (mg) within 24 hours to 1 (R#1) of (R #1). The facility also failed to ensure accurate medication administration practices consistent with the resident's prescribed regimen.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored securely when a medication cart remained unlocked and unattended on the 200 Hall. This failure created the potential for unauthorized access to medications, including controlled substances, for 1 of 1 medication carts observed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's Advance Directives (a document which provides an individual's wishes for emergency and lifesaving care) were honored for 1 (R #101) of 1 (R #101) residents when staff provided cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation) to R #101 when the resident had a documented Do Not Resuscitate (DNR; lifesaving measures are not desired) Advanced Directive on file at the facility. If staff do not follow a resident's Advanced Directives, then the resident may feel undignified and as if they do not have control over her own choices.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure: 1. Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of opening date for 5 (R #8, R #12, R #15, R #32 and R #66) of 5 (R #8, R #12, R #15, R #32 and R #66) residents reviewed. This deficient practice is likely to lead to all five residents receiving medications that are less effective or expired. 2. Staff secured medications and made them inaccessible to unauthorized staff for one medication cart in the 100 hall and one treatment cart in the 400 hall. Improperly stored medications could result in a resident, staff member, or visitor taking medications not prescribed to them. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the low temperature dishwasher (low temperature dishwashers utilize chemicals for sanitation) worked properly to sanitize the dishes and was repaired timely. If the facility is not properly sanitizing the dishes, then there was the potential for foodborne illnesses which could affect all of the 116 residents listed on the resident census provided by the Administrator on 06/22/25.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: Lock a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) on the 400 Unit when not in use and unattended. Lock a wound care treatment cart on the 100 Unit when not in use and unattended. These deficient practices had the potential to affect all residents on the 400 and 100 Units. If staff fail to lock unsupervised treatment carts, then residents could obtain medical equipment which could result in injury or death.

Inspectors wroteBased on interview and record review, the facility failed to: - Ensure appropriate treatment and services for 1 (R #26) of 1 (R #26) resident who had urinary retention (a condition that occurs when a person is unable to empty their bladder, either partially or completely) and an indwelling urinary catheter (a thin, flexible tube which drains urine from the bladder). - Ensure an indwelling urinary catheter was used only when clinically necessary for 1 (R #1) of 1 (R #1) resident. These deficient practices could place the residents at risk for infection or diminished quality of life.

Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Ensure a resident received a prescribed anticoagulant (AC, blood thinner) medication at admission to the facility for 1 (R #69) of 1 (R #69), when staff failed to administer warfarin (blood thinner) as ordered by the provider. This deficient practice is likely to lead to increased R #69's risk of blood clot formation. 2. Ensure a resident received prescribed antipsychotic medication (used to treat mental health conditions that involve psychosis) in a timely manner for 1 (R #1) of 1 (R #1) resident, when staff failed to administer the antipsychotic medication as ordered by the provider. These failures have the potential to lead to the reduction of the medication's effectiveness and potentially lead to a return or worsening of the symptoms.

Inspectors wroteBased on observation and interviews, the facility failed to ensure a call light was within reach for 2 (R #5 and #22) of 2 (R #5 and #22) residents observed. If the facility is not ensuring the call light is within residents' reach, then residents are unable to request immediate assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's right to retain his personal property for 1 (R #34) of 1 (R #34) resident when staff removed a resident's Christmas lights from his room and failed to put them back up after the safety rating was approved for use. If staff do not respect a resident's right to personal property, then the resident may become angry, frustrated, and disrespected.

Inspectors wroteBased on record review, observation, and interview, the facility failed to create an accurate 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 2 (R #60, #86) of 2 (R #60, #86) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care residents' need, and residents may not attain or maintain their highest level of well-being.

Inspectors wroteBased on interviews, record reviews and observations, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1(R #1) of 1(R #1) residents observed, when staff failed to report or repair a broken wall inside R #1's room. This deficient practice is likely to lead to the following: 1. Creating an environment conducive to mold and mildew growth. 2. Mice can enter through the broken wall and cause significant damage, spread diseases, and create unpleasant odors. They can chew through insulation, wiring, and other building materials, potentially leading to fires or structural problems.

Inspectors wroteBased on record review and interview, the facility failed to follow a physician's order and professional standards of practice for 1 (R #1) of 1 (R #1) residents reviewed for medication administration. This deficient practice could likely cause staff to incorrectly administer a medication, which could cause the gastronomy tube (g-tube; a tube inserted through the belly that brings nutrition directly to the stomach) to clog and or incompatible medications to be administered together.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure staff served meals that were attractive and palatable (pleasant to taste) for 6 (R #'s 2, 7, 29, 36, 49, and 309) of 10 (R #'s 2, 7, 15, 29, 36, 37, 39, 49, 104 and 309) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight.

Inspectors wroteBased on observation and interview record review, the facility failed to serve food under sanitary conditions in accordance with professional standards of food service safety when staff failed to monitor the internal temperature of food to ensure it is safe for consumption. This deficient practice is likely to result in residents getting a food borne illness and could likely affect all 115 residents identified on the census list provided by the Administrator on 02/12/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Minimum Data Set (MDS; a federally mandated standardized assessment tool completed by facility staff, that measures health status in nursing home residents) assessments included accurate insulin use information for 2 (R #2 and R #3) of 2 (R #2 and R #3) residents reviewed for MDS accuracy. This deficient practice could likely result in residents not receiving the most optimal and personalized care required to meet their highest practicable outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to support residents in activities of daily living by not offering showers to residents in accordance with a pre-planned and agreed upon schedule and not answering call lights in a timely manner for 3 (R #2, R #73, and R #309) of 3 (R #2, R #73, and R #309) residents sampled for ADLs. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs) and showers.

Inspectors wroteBased on observation and interview, the facility failed to properly store medications in medication carts by allowing loose medications under the medication cards (cards that contain individually sealed tablets in which the medication must be pushed through the foil in order to take the medication). This deficient practice has the likelihood to result in all residents on hall 300 and 400, as identified on the census list provided by the administrator on [DATE], to receive expired or improperly temperature-controlled medications that have either lost their potency or effectiveness.

Inspectors wrote*This is a repeat deficiency. Based on observation, record review, and interview, the facility failed to take into consideration food preferences (choices) for 2 (R #36 and R #49) of 2 (R #36 and R #49) residents by not providing an alternative meal substitution as per resident request. This deficient practice could likely affect all 116 residents identified on the facility census provided by the Administrator (ADM) on 03/25/24 and could likely result in residents feeling frustrated that staff do not support their rights and choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care for 1 (R #309) of 1 (R #309) resident reviewed for oxygen therapy when staff failed to: - Ensure physician orders for oxygen therapy were entered into the resident's medical record. - Ensure O2 tubing was properly dated and labeled with the last equipment change. This deficient practice could likely result in residents not getting the therapeutic results required for optimal health.

Inspectors wrote*This is a repeat deficiency. Based on interview, observation, and record review, the facility failed to serve food according to the presented menu. This deficient practice has the potential to affect all 116 residents listed on the census presented by the Administrator (ADM) on 03/25/24 and could likely result in resident frustration and/or dissatisfaction with meal options and therefore residents' may not receive required nutrition to maintain their best health. A. On 03/26/24 at 9:42 am during an interview, R #37 stated there was not much variety, and the menu was not followed. R#99 B. Record review of posted lunch menu for 03/27/24 revealed staff to serve the following for lunch: Country fried steak with mushroom gravy or fish tacos with flour tortilla, dinner roll, pineapple tidbits, seasoned potato wedges, and seasoned green beans or Mexican street corn. C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light was functioning as intended for 1 (R #3) of 1 (R #3) resident reviewed for call system functioning. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance.

Inspectors wrotePAST NOT COMPLIANCE Based on record review and interview, the facility failed to notify the physician for 1 (R #68) of 3 (R #68, R #7, and R #49) residents, when they failed to immediately notify R #68's physician of the resident's missed seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) medications. This deficient practice result in the resident's physician being unaware of resident's current condition, resulting in delayed treatment.

Inspectors wrotePAST NOT COMPLIANCE Based on record review and interview, the facility failed to keep a resident free from significant medication errors for 1 (R #68) of 3 (R #68, R #79, and R #7) residents randomly sampled, when they failed to administer R #68's levetiracetam (an anti-seizure medication) on the evening of 12/14/2023 and morning and evening of 12/15/2023 as per physician's order. This deficient practice resulted in R #68 having adverse side effects such as breakthrough seizures (occur when a person has a seizure after controlling their condition with medication for at least 12 months.)

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that six of six residents (Resident (R)23, R83, R50 , R65, R79 and R90 ) reviewed for tracheostomy (trach) care out of a total sample of 33 residents had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death. On 12/13/22 at 2:32 PM, the Administrator, the Regional Nurse, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F695-K: Respiratory/Tracheostomy Care and Suctioning. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure staff followed adequate infection control measures to prevent the spread of COVID-19 among 36 of 113 facility residents. A COVID-19 outbreak began on 11/22/22 with 36 cases of facility-acquired infections from 11/22/22 to 12/12/22. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure two residents observed of a sample of 33 residents (Resident (R) 94 and (R)20) had emergency calling devices or alternative communication devices accessible while in their beds. These failures had the potential to delay needed assistance and negatively impact the quality of life.

Inspectors wroteBased on record review and interview the facility failed to report to the State Survey Agency an incident resulting in an injury for one (Resident (R) 516) of 3 residents sampled for falls. This deficient practice could likely result in preventing staff from determining the cause of the incident and identifying the need for staff training and implementing interventions to address such incidents in the facility.

Inspectors wroteBased on record review and interview the facility failed to conduct a thorough investigation for one (Resident (R) 516) of 3 residents sampled for falls. This deficient practice could likely result in preventing staff from determining the cause of the incident and identifying the need for staff training and implementing interventions to address such incidents in the facility.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure two of 33 sampled resident's (Resident (R) 27 and R70) care plan interventions were implemented for R27's nutritional risk monitoring of meal intakes, and failed to ensure a care plan was developed for R70's prescribed neck brace, oxygen therapy and C-PAP [a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders]. The facility's failure had the potential to increase R27's risk of insufficient nutritional intake and R70's risk for potential of respiratory and neck brace complications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide quality care in accordance with physician orders for one (Resident (R) 517) out of 33 sampled residents. The facility failed to notify the physician of elevated blood sugars in accordance with physician's orders. This had the potential for the resident to not receive timely care and services related to her high blood sugars.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one (Resident (R)516) of three sample residents reviewed for falls received adequate supervision and assistive devices to prevent accidents. The facility failed to maintain adequate documentation concerning R516's injury and determine the root cause of the accident.

Inspectors wroteBased on observations, record review, staff interview, and facility policy review, the facility failed to ensure one of three sample residents (Resident (R) 1) reviewed for catheters and urinary tract infections (UTIs) received appropriate catheter treatment and services to potentially prevent UTIs.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to ensure the menu was followed regarding portion size for one resident of six reviewed for meal portions. (Resident (R)324). The had the potential for the resident's nutrition not being met.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to offer food according to diet orders for two out of 33 sampled residents (Resident (R)516 and R518). This failure had the potential to place R516 and R518 at risk for nutritional issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was operating for one out of 33 sampled residents (Resident (R)516). The call light had been inoperable for at least two months and although it had been reported to staff, it had not been repaired. This had the potential for the resident's needs not being met in a timely manner.