F0656

E

Failure to Accurately Reflect Oxygen Use and Ankle Edema in Resident Care Plans

Clayton, New Mexico Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement accurate, comprehensive care plans for two residents. One resident with COPD, Alzheimer's disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order dated 08/05/25 for oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of this resident's care plan dated 08/04/25 showed no indication that the resident utilized oxygen as needed. During an interview on 02/13/26 at 9:20 am, the DON confirmed that the resident does use oxygen as needed and acknowledged that the care plan does not indicate this and that it should.

For another resident with diagnoses including Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia, surveyors observed the resident asleep in a wheelchair in the dining area on 02/10/26 at 10:30 am, with legs and ankles appearing red and swollen. Record review showed a physician progress note dated 08/21/24 documenting a diagnosis of ankle edema. However, the resident's care plan revised on 07/31/25 contained no indication of ankle edema. In an interview on 02/13/26 at 9:30 am, the DON confirmed that the resident does have ankle edema and stated that the resident's care plan did not meet her expectations because it should include the ankle edema and does not.