Odelia Healthcare: Missing Diagnosis Led to Rehospitalization - NM
The resident, identified in inspection documents only as Resident 7, was admitted on June 14, 2025. The hospital discharge paperwork from that same day listed hematuria, blood in the urine caused by injury during a Foley catheter insertion, as a diagnosis requiring ongoing care. It also noted urinary tract infections with hematuria and flagged referrals to physical and occupational therapy.
The admission record Odelia created that day listed metabolic encephalopathy. Hematuria was not on it.
Two days later, a provider progress note contained no documentation of treatment for the hematuria. By June 17, the care plan and the federally required Minimum Data Set assessment had both been completed. Neither included hematuria. The MDS Coordinator, interviewed by inspectors on September 3, explained why: the facility did not include diagnoses on the active list if it was not treating the condition in-house.
Nobody had decided to treat it.
By June 19, staff documented that the resident was showing a significant decline in food and fluid intake, seemed different than usual, was tired, weak, confused, and drowsy. The symptoms had gotten worse since they were first noted. Confusion had increased. The resident had developed general weakness.
On June 21, Resident 7 was sent back to the hospital. The primary diagnosis on the discharge paperwork from that second admission: hematuria. The resident had been rehospitalized for the exact condition the facility had never documented, never planned for, and never treated.
When the resident returned from the hospital, a progress note dated June 26 recorded that nursing staff observed a small amount of blood in the resident's brief and that a urinalysis had been ordered. The urinalysis had not yet been obtained.
The months that followed did not improve. A provider note from August 20 still contained no documentation of treatment for hematuria. The next day, August 21, staff documented urine retention, a bladder scan reading greater than 999 milliliters, and an attempted catheter insertion that failed because of severe resistance and severe pain. The resident had abdominal tenderness, persistent discomfort, decreased urine output over one to two days, and lower severe abdominal pain.
State inspectors arrived on September 3 and conducted interviews that afternoon. The Director of Nursing confirmed that staff had not documented the hematuria diagnosis in the admission record, the care plan, or the MDS. She said the MDS Coordinator bore responsibility for the MDS entry. She acknowledged that staff had also failed to complete the urinalysis the provider had ordered. Her expectation, she told inspectors, was that all hospital diagnoses should be entered into a resident's MDS and care plan so the person receives appropriate care.
That expectation was not met for Resident 7.
The inspection classified the violation at a level of minimal harm or potential for actual harm, a designation that reflects the regulatory floor of the finding rather than the resident's experience. A missed diagnosis. A rehospitalization. A failed catheter insertion months later, documented as causing severe pain. A lab test ordered and never completed.
Resident 7 came to Odelia Healthcare needing care for a specific, documented injury. The facility's own coordinator acknowledged the facility's reasoning: if they weren't treating it, they didn't list it. What the records don't explain is who decided not to treat it, or when, or whether anyone told the resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Odelia Healthcare from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Odelia Healthcare in Albuquerque, NM was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection documents only as Resident 7, was admitted on June 14, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.