Odelia Healthcare: Blood Diagnosis Missing from Records - NM
The resident was admitted June 14 with metabolic encephalopathy, a reversible brain disorder caused by chemical imbalances. Hospital discharge papers from that same day specifically ordered wound care for hematuria — the medical term for blood in urine — and physical occupational therapy for the condition.
But when staff completed the resident's MDS assessment three days later, they left out any mention of the hematuria diagnosis. The MDS is a federally mandated assessment tool that nursing homes use to develop care plans and determine appropriate treatments for each resident.
Five days after admission, the resident's condition deteriorated sharply. A June 19 evaluation documented significant decline in food and fluid intake. The resident appeared tired, weak, confused and drowsy, with increased confusion and generalized weakness.
Two days later, the resident was back in the hospital.
The June 21 hospital discharge documentation listed hematuria as the primary diagnosis. The resident had been readmitted specifically for hematuria, and doctors developed a new plan of care focused on treating the blood in urine.
When the resident returned to Odelia Healthcare, nursing staff observed blood in their brief and ordered a urinalysis to check for infection. But as of June 26, the urinalysis had not been obtained.
Even after the hospital readmission and return, staff still failed to include the hematuria diagnosis in the resident's updated MDS assessment.
Federal inspectors interviewed the MDS Coordinator on September 3. The coordinator acknowledged that the facility had not included the resident's gross hematuria diagnosis in either MDS assessment — not the initial one from June 17 or the updated version from June 26.
The coordinator defended the omissions, stating both assessments were correct. The coordinator explained that resident symptoms were not included on active diagnosis lists if the facility was not treating the condition in-house.
This reasoning directly contradicted the hospital's discharge orders, which specifically required the nursing home to provide wound care and therapy for the hematuria.
The Director of Nursing confirmed during a separate interview that the gross hematuria diagnosis was missing from the resident's MDS assessments. The director placed responsibility on the MDS Coordinator, stating that person was responsible for ensuring the diagnosis was properly included.
Federal regulations require nursing homes to conduct comprehensive assessments of each resident's functional, medical and psychological status. These assessments form the foundation for individualized care plans and treatment decisions.
When facilities fail to accurately document diagnoses in MDS assessments, they cannot develop appropriate care plans or provide individualized treatment. This places residents at risk for unmet needs, delayed interventions and adverse health outcomes.
The resident's case illustrates these risks in stark terms. Despite clear hospital orders for specific wound care and therapy, the nursing home's assessment records contained no indication that such treatment was needed.
The omission meant that anyone reviewing the resident's care plan would have no documentation of the blood in urine condition that had already required one hospital readmission. Staff observations of blood in the resident's brief and orders for urinalysis testing were noted in progress notes, but the underlying diagnosis remained absent from the formal assessment.
The facility's explanation that diagnoses weren't included if not treated in-house created a dangerous gap. Hospital discharge orders specifically directed the nursing home to provide wound care and physical therapy for the hematuria, making it a condition the facility was indeed supposed to treat.
The MDS Coordinator's insistence that both assessments were correct despite the documented hospital orders and observed symptoms suggests a fundamental misunderstanding of assessment requirements.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. But for the resident involved, the assessment failures occurred during a period of declining health that led to hospital readmission.
The resident's experience of returning to the hospital with the same condition that brought them to the nursing home initially raises questions about whether proper care planning might have prevented the readmission. Without accurate documentation in the MDS, staff lacked the formal assessment framework needed to address the diagnosed condition.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Odelia Healthcare in Albuquerque, NM was cited for violations during a health inspection on September 3, 2025.
The resident was admitted June 14 with metabolic encephalopathy, a reversible brain disorder caused by chemical imbalances.
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.