Fatal Medication Error
Late in August 2024, Thaddeus “Tuk” Koslik went to visit his father at Morada Senior Living’s Albuquerque assisted living and memory care facility. Sadly, Tuk never had the chance to speak to his father. He was sleeping, and three days later, he would be dead. See article here.
Joe Koslik, a retired railroad worker known for his calm temperament, tragically died from a medication error of the most serious sort. His syringe did not contain nausea medication but Dilaudid, a powerful opioid painkiller. The 76-year-old was given the opioid twice in less than 24 hours.
After the family filed a complaint with New Mexico’s Division of Health Improvement, the agency’s investigators confirmed that there were issues with understaffing and how staff handled medication.
Furthermore, the fatal error was not reported within 24 hours, and an investigation was not conducted within five days, as required by state law.
The Kosliks trusted assurances from administrators at Morada Albuquerque that they could care for Joe, whose extensive medical needs included heart and lung problems, kidney disease, and dementia. Joe also needed help to get out of bed and to use the toilet.
This trust was broken, however, in an unreversible act that ended the life of Joe Koslik.
The family filed a wrongful‑death lawsuit in state district court last November against Morada Senior Living, its parent company Discovery Senior Living, and a separate company, Ambercare Hospice, who the family hired to provide periodic nursing care.
In addition to alleging that the medication errors on Aug. 30 and 31, 2024 led to Joe’s death, the lawsuit mentions other instances of neglect. For example, Tuk at one point found his dad in urine-soaked clothing, the lawsuit states. Footage from a camera installed by the family also caught a staffer manhandling Joe while helping change his clothes, “throwing Mr. Koslik Jr.’s body around like a rag doll and yelling at him for not complying,” according to the lawsuit.
While attorneys for Morada and Discovery wrote that Morada “met or exceeded the applicable standard of care for a licensed assisted living facility in New Mexico” in Koslik’s case, there is a great deal of evidence that the facility did not provide an adequate level of care, impacting numerous residents in the months before Joe’s death.
During a round of surprise inspections in May, the state flagged problems with the facility, finding more issues after closing seven investigations sparked by complaints that summer.
In an investigation completed in December 2024 following Koslik‘s death, state inspectors identified signs of a broader breakdown in medication safety at Morada. They were concerned with how Morada trained their staff, stored medications, and kept records, including how the facility documented and reported medication errors.
Unfortunately, Morada is not alone in failing to care for its residents. New Mexico In Depth found similar problems at assisted living facilities across the state after reviewing hundreds of inspection reports.
The state of New Mexico is partly to blame, due to its lax oversight of these facilities.
In March 2024, New Mexico In Depth reported that 40% of the state’s assisted living facilities had not been inspected in more than four years, excluding virtual check-ins that occurred early in the COVID-19 pandemic.
When state inspectors did conduct surprise inspections at long-term care facilities across the state, 88% of 91 facilities included in the sweep failed at least one aspect of the inspections, ranging from “egregious incidents requiring immediate reporting to administrative violations of rules and regulations.”
Morada belonged to the worst category of homes. The state referred Morada to the state’s Abuse, Neglect and Exploitation hotline because during the sweep, regulators encountered a family searching the halls for a resident who had wandered away. She was later found about a mile away.
Despite the state’s promises to do better with inspections, and despite discovering a range of serious issues during the 2024 surprise sweep, the state conducted no proactive inspections of assisted living facilities in 2025, New Mexico In Depth found.
“The team didn’t have the capacity to do it,” then-New Mexico Health Care Authority Deputy Secretary Alex Castillo-Smith explained in an interview in April, promising that would change this year.
Unlike nursing homes, assisted living facilities are not regulated by the federal government. Instead, it is states that set the rules and enforce them.
The lack of a state requirement in New Mexico to report staff on duty makes it difficult to know how caregivers were on duty when Joe got the wrong medication at 5 p.m. on August 30 and again 16 hours later.
Additionally, state law says facilities must have “sufficient number of staff” for basic care, but sets a low bar: one caregiver for every 15 residents during the day. At night, facilities with 16 to 30 residents are required to have just one caregiver awake and on-site, with only one other person available if needed.
It is unclear how the state confirms facilities are following these rules.
The state also sets low requirements for training as well, as staff members can provide unsupervised care for residents after a mere 16 hours of training. No nursing degree or medical training is required — just a background check.
This is incredibly low compared to nursing homes, where federal rules require staff to complete 75 hours of classroom and hands-on training before they’re certified.
Taken together, gaps in staffing, training, oversight, and inspections create conditions in which serious harm is not just possible, but foreseeable, long-term care experts say.
As shown by reports from facilities throughout the state, the harm is already present.
For instance, a facility administrator was discovered using a resident’s ATM card for $1,000 in cash withdrawals. At another facility, staff restrained a resident by wrapping them in a blanket and tying their ankles with a shirt.
Choosing the right facility in the first place is nearly impossible, as there is no rating system for assisted living homes in New Mexico. While there are placement services, these are often paid by facilities, creating a conflict of interest.
State databases aren’t much help either, as recent reports of inspections at Morada are “temporarily unavailable.”
The death of Joe Koslik still haunts his son. “I don’t think it will ever rest well with me if I don’t feel like some justice was done.”
Had the Kosliks not installed a camera in Joe’s room, justice would be much harder to come by, as the lack of transparency afforded by state regulations and the facility itself would have kept the family completely in the dark about what happened to Joe.