Los Alamos Wellness & Rehab: Resident Left at ER - NM

The resident, identified in inspection records only as Resident 43, had been sent to the emergency room from Los Alamos Wellness & Rehabilitation on January 29, 2026, after a fall. She arrived at the hospital at approximately 7:30 that evening. By 10:16 PM, she had been evaluated and discharged. She was ready to go back.

Nobody came for her until 9:00 the next morning. That is eleven hours.

The emergency room nurse, identified in the inspection report as the ERN, made several calls to the facility after the discharge. The calls went to voicemail. She kept trying until she reached the administrator directly on her cell phone. The administrator told her that staff was on the way.

Staff was not on the way.

The ERN called the administrator approximately three more times after that initial assurance. Then the administrator stopped answering.

Resident 43's cognitive score, documented by facility staff, was a 2 on the Brief Interview for Mental Status, a scale that runs to 15. A score of 2 indicates profound cognitive impairment. Staff had also documented that she was frequently incontinent of urine and always incontinent of bowel movements, and that she required substantial to maximal assistance with toileting, meaning a helper was doing more than half the physical work just to keep her clean.

That is the person who spent the night in an emergency room, confused and trying to climb out of bed, while the nursing home that was responsible for her care stopped picking up the phone.

The ERN told inspectors that Resident 43 became more confused as the night went on.

When inspectors interviewed the administrator on March 26, 2026, she confirmed the timeline. She said she had been notified that Resident 43 was discharged at approximately 10:30 PM on January 29. She acknowledged that the facility does not have 24-hour transportation. She said the facility always tries to pick residents up as soon as possible after a hospital discharge.

She also said that once a resident is discharged from a hospital, the hospital is responsible for that person until the facility can retrieve them.

The hospital's emergency room nurse described a different reality. She described a woman who could not orient herself, who kept trying to get up, who had no one with her through the night, and who grew worse the longer she waited. She described an administrator who gave assurances and then became unreachable.

The inspection was a complaint survey, meaning someone reported this situation to regulators. It was completed on March 30, 2026, two months after the night in question.

The facility's own records confirmed the gap. A nursing progress note documented that Resident 43 was sent to the ER on January 29 at 7:44 PM and returned from the hospital on January 30 at 9:30 AM. A separate entry in her medical record showed no discharge from the facility on January 29, consistent with the account that she never actually left the facility's care in any administrative sense, even as she sat alone in an emergency room in the middle of the night.

The administrator's position, that the hospital bears responsibility for a discharged patient until the nursing home arrives, did not appear to account for what that actually looks like in practice: a profoundly confused woman, always incontinent, needing maximal help just to use a toilet, sitting in an ER bay through the early hours of January 30 while calls to her nursing home rang out to voicemail.

The inspection report does not describe what, if anything, Resident 43 understood about why no one came.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Los Alamos Wellness & Rehabilitation from 2026-03-30 including all violations, facility responses, and corrective action plans.

Additional Resources

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