F0656

D

Failure to Complete Accurate and Timely Baseline Care Plans on Admission

Roswell, New Mexico Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s development of accurate baseline care plans within 48 hours of admission for multiple residents. For one resident with metabolic encephalopathy and end-stage renal dialysis, the baseline care plan lacked any information in the Social Services, Rehabilitative Services, and Activities sections, and incorrectly listed a regular diet in the Nutritional Services section. The DON stated this baseline care plan was not accurate and not completed to her expectations. Another resident admitted with fractures of the left humerus and right radius, depression, and anxiety had a baseline care plan that was not completed and signed until thirteen days after admission, which the DON confirmed did not meet her expectations due to the delay.

A third resident admitted with a sacral fracture, essential hypertension, osteoarthritis, and urinary retention had a baseline care plan marked completed and fully signed eighteen days after admission, which the DON acknowledged did not meet her expectations. For a fourth resident with multiple serious conditions including a displaced intertrochanteric fracture of the right femur, chronic respiratory failure with hypoxia, vertebral fractures, gastrostomy status, history of chemotherapy and irradiation, and long-term anticoagulant use, observation showed a feeding pump connected to a tube in the abdomen and the resident reported having a feeding tube for eight years. However, the baseline care plan did not indicate that the resident was a current smoker, did not document current anticoagulant use, and contained no information in the Nutritional Services section. The DON stated this baseline care plan should have documented smoking status, anticoagulant use, and feeding tube use but did not.