ALBUQUERQUE, NM - State health inspectors documented multiple violations at Albuquerque Heights Healthcare and Rehabilitation during an April 2025 inspection, including concerns about food safety practices for dialysis patients and widespread maintenance failures throughout the facility that created potential safety hazards for residents.
Food Safety Failures Impact Dialysis Patient
The inspection revealed concerning food handling practices affecting a resident with serious medical conditions including end-stage renal disease, congestive heart failure, and diabetes. The 87-year-old resident, who required regular dialysis treatments, was routinely served lunch meals that were left unrefrigerated on her bedside table for hours while she received treatment at an outside facility.
During the April 7 observation, inspectors watched as staff delivered a lunch tray consisting of tamale and black beans to the resident's room at 12:45 pm, leaving it on the bedside table despite knowing she was at dialysis. The meal remained at room temperature for nearly three hours. When the resident returned and began eating the food at 3:37 pm, a nursing assistant intervened, stating "the food was more than two hours old" and removed the tray.
This practice posed significant health risks for a medically vulnerable resident. Food left in the temperature danger zone between 40°F and 140°F for more than two hours can develop dangerous levels of bacteria. Common foodborne pathogens like Staphylococcus aureus, Salmonella, and Clostridium perfringens multiply rapidly at room temperature, potentially producing toxins that cannot be eliminated even if food is later reheated.
For a resident with multiple chronic conditions, foodborne illness could have severe consequences. End-stage renal disease compromises the immune system, making patients more susceptible to infections. Additionally, the gastrointestinal distress from food poisoning could dangerously disrupt fluid and electrolyte balance in someone dependent on dialysis. Dehydration and electrolyte imbalances could trigger cardiac complications in a patient with existing heart failure and cardiomyopathy.
The resident told inspectors she typically returned from dialysis between 2:00 pm and 3:00 pm to find her cold lunch waiting. Though she stated she was hungry after treatment and had asked staff to heat her meals, her requests were not fulfilled. When interviewed, nursing staff acknowledged the practice of leaving trays for the resident but could not specify how long meals typically sat unrefrigerated.
Dietary Standards Violated
The facility's Dietary Manager expressed surprise at the practice when interviewed on April 11, stating "he would not expect staff to leave a meal tray on the resident's bedside table if the resident was at dialysis." He outlined proper protocols that should have been followed - either returning the tray to the kitchen for proper storage or preparing fresh food when the resident returned.
Standard food safety protocols in healthcare facilities require strict temperature control for all patient meals. Hot foods must be maintained above 140°F and cold foods below 40°F. When meals cannot be served immediately, they should be returned to temperature-controlled storage. For residents with predictable absence patterns like dialysis appointments, facilities typically implement systems to ensure fresh, properly heated meals are available upon return.
The failure to follow basic food safety protocols was particularly concerning given the resident's diabetes diagnosis. Proper nutrition timing and food quality are critical for blood sugar management in diabetic patients. Consuming potentially contaminated food could lead to gastrointestinal illness that would complicate glucose control and potentially interfere with the effectiveness of dialysis treatments.
Widespread Environmental and Safety Hazards Documented
Beyond food safety concerns, inspectors documented extensive maintenance failures throughout the facility that created unsafe conditions for residents. The problems were particularly concentrated in the resident rooms on the second floor, where multiple safety hazards and environmental issues went unaddressed.
Room 207 contained multiple hazards including broken furniture and damaged flooring. Inspectors found a wardrobe with a broken door and missing bottom drawer, creating sharp edges and unstable surfaces. The flooring near the resident's bed was ripped, presenting a significant trip hazard. This is especially dangerous in a healthcare setting where residents may have mobility limitations, use walkers or wheelchairs, or have balance issues due to medications or medical conditions. Falls are a leading cause of injury and death in nursing home residents, and environmental hazards like torn flooring substantially increase fall risk.
The room's shower area was being used for storage of large foam pads and cushions rather than being available for resident use. This practice not only denies residents access to bathing facilities but creates additional safety concerns. Storage of non-waterproof materials in wet areas can promote mold growth, and blocked shower access could impede proper hygiene maintenance for residents.
Critical Safety Infrastructure Compromised
Perhaps most concerning was the missing end piece on a handrail directly outside room 207, which left sharp metal edges exposed. Handrails are essential safety features in healthcare facilities, providing stability support for residents with mobility challenges. The exposed sharp edges created a laceration risk, particularly dangerous for residents on blood thinners or with conditions affecting wound healing such as diabetes.
Room 213 presented both safety and dignity concerns with broken blinds that compromised resident privacy, walls covered with a green gum-like substance in multiple spots near one bed, and a pervasive urine odor that suggested inadequate cleaning and possible infection control issues. Strong odors in resident rooms can indicate improper cleaning of bodily fluids, which poses infection risks, particularly in shared rooms where cross-contamination between residents is possible.
Memory Care Unit Shows Systemic Maintenance Failures
The Memory Care Unit exhibited facility-wide maintenance problems including ceiling vents throughout the entire unit clogged with dust buildup. Dirty ventilation systems can circulate dust, allergens, and potentially harmful particles, exacerbating respiratory conditions common in elderly populations. For residents with dementia who may not be able to communicate breathing difficulties, poor air quality poses particular risks.
Inspectors also noted broken light fixtures, water-stained ceiling tiles suggesting possible leaks, and gaps around fire safety equipment including sprinkler heads. These issues indicate systemic maintenance failures that could compromise both daily quality of life and emergency response capabilities.
Additional Issues Identified
Other violations documented during the inspection included broken thermostats affecting room temperature control, damaged closets and dressers limiting residents' ability to store personal belongings safely, missing drawer components in multiple rooms, and broken disposable glove holders on walls, potentially impacting infection control practices. The facility's Maintenance Director acknowledged during the inspection that he was the sole maintenance staff member and relied on nurses and aides to submit electronic work orders for needed repairs.
Industry Standards and Systemic Failures
Healthcare facilities are required to maintain safe, functional, and dignified living environments for all residents. Federal regulations mandate that nursing homes must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. The extensive list of unaddressed maintenance issues throughout multiple rooms and common areas indicates a breakdown in the facility's maintenance request and response system.
The pattern of violations suggests inadequate staffing, poor communication systems, or insufficient prioritization of resident safety and comfort. With only one maintenance staff member serving the entire facility, the ability to address both routine maintenance and urgent safety issues appears severely compromised. Standard practice in healthcare facilities includes regular room inspections, preventive maintenance schedules, and rapid response protocols for safety-related repairs.
The Memory Unit Director confirmed the environmental and safety concerns during the inspection and acknowledged these issues required repair, yet the problems had persisted long enough to be documented during the state survey, suggesting a lack of effective oversight and quality assurance processes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Albuquerque Heights Healthcare and Rehabilitation from 2025-04-15 including all violations, facility responses, and corrective action plans.
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