Resident 203 disappeared from the facility on September 1, 2024, triggering an elopement investigation that revealed multiple safety system failures.
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The violation at Albuquerque Heights Healthcare and Rehabilitation came to light during a complaint inspection on August 14.
The violations involved antipsychotic drugs, antidepressants and anxiety medications administered to newly admitted residents starting August 12.
The nurse also gave Tylenol for pain around 10:30 PM that night but failed to complete mandatory documentation.
The woman, identified in state inspection records as Resident #14, fell on July 26 around 6:30 or 7:00 in the evening.
Her federally mandated assessment from June 29 showed no memory impairment.
Resident #1 had been classified as high risk for elopement.
Federal inspectors documented ten separate system failures dating back to February 2024.
The Director of Nursing confirmed during an August 15 interview that no registered nurse was present in the facility on either date.
Federal inspectors arrived at Taylorville Care Center on August 12 to find no dietary manager on duty.
Resident 24 at South Shore Rehabilitation and Nursing Center was supposed to receive showers twice weekly according to their care plan.
The 85-year-old woman had been admitted after acute kidney failure and unsteadiness on her feet led to hospitalization.