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F0756
E

Failure to Complete Monthly Pharmacy Reviews and Implement Approved Recommendations

Santa Fe, New Mexico Survey Completed on 11-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a licensed pharmacist performed the required monthly drug regimen reviews for several residents over multiple months. Specifically, pharmacy reviews were not completed for three residents from August 2024 through October 2025. Additionally, pharmacy recommendations that were approved by providers were not implemented for two residents. These recommendations included discontinuing certain pain medications and monitoring for dermatological side effects related to specific prescriptions. In another instance, recommendations to monitor for involuntary movements were approved but not carried out as ordered. Record reviews confirmed that the Medication Regimen Review (MRR) documentation was either missing or not acted upon, and interviews with the DON verified that these omissions occurred and should have been addressed. The failures included not adding new orders to the electronic medical record (EMR) after provider approval and not following through with monitoring or discontinuation of medications as recommended by the pharmacist and approved by the provider.

See complete original report
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