F0842

E

Inaccurate Dental, Activity, and Skin Documentation in Resident Records

Silver City, New Mexico Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves failures to maintain complete and accurate medical records for multiple residents. One resident’s admission assessment, dated 11/17/25, documented that the resident had no natural teeth or tooth fragments and was edentulous, while direct observation and interview showed the resident had several broken, discolored teeth that needed to be pulled. An LPN and the DON later confirmed that the resident was not edentulous and that the admission assessment was inaccurate, despite the expectation that staff accurately assess and document dental status.

Additional documentation inaccuracies were identified in activity and skin records. For one resident, a family member reported the resident wanted to attend Christian church services and was told Catholic services were available, but the activities participation records from October to December 2025 contained no documentation of church attendance, even though the unit manager and activities director stated the resident was taken off the secure unit for church. Another resident’s care plan called for encouragement to participate in activities and provision of one-to-one programs as needed, yet the activities participation records for the same period showed no one-to-one activities documented, despite the unit manager stating these occurred at least daily. A further resident was observed with a bleeding right elbow wound that was bandaged by an LPN, and later with a dressing that was falling off and appeared unchanged since the injury; however, a skin assessment dated 01/08/26 documented no skin issues. The wound care nurse and DON confirmed the presence of the wound and that the skin assessment was inaccurate, despite expectations for at least weekly, accurate skin assessments.