F0658

E

Failure to Complete AIMS Assessments, Provide Ordered Meal Assistance, and Use Appropriate Injection Equipment

Rio Rancho, New Mexico Survey Completed on 02-11-2026

Penalty

Fine: $17,215

Summary

The deficiency involves the facility’s failure to ensure that services met professional standards for residents receiving antipsychotic medications, assistance with meals, and injectable medications. One resident with schizophrenia, admitted in late November, had physician orders for Risperdal and Cogentin and demonstrated abnormal involuntary movements, including uncontrolled arm movements and frequent leg twitches. Record review showed only two AIMS assessments completed over several months despite the DON’s statement that AIMS assessments are to be done quarterly for residents on antipsychotics, and the DON acknowledged that the resident’s known abnormal movements should have been reflected on the AIMS tool. Another resident with major depressive disorder, dementia with severe behavioral disturbance, and suicidal ideations was ordered Aripiprazole along with antidepressants, yet record review revealed that no AIMS assessment had been completed since admission, which the DON confirmed should have occurred due to the antipsychotic use.

The facility also failed to follow physician orders and the care plan for meal assistance for a resident with impaired physical functioning. This resident’s care plan documented a need for substantial/maximum assistance with eating, and a physician order directed staff to provide feeding assistance with every meal. During observation, the resident was seen eating alone in the room, and the meal ticket indicated a requirement for assistance/supervision for all meals. The ADON confirmed that the resident was care planned to receive assistance for all meals and acknowledged that no staff member was present during the observed meal, and the DON later confirmed that feeding assistance for every meal had been ordered and care planned but was not provided at that time.

In addition, the facility did not use appropriate equipment for administering an injectable medication. A resident had a physician order for heparin 5,000 units per 1 mL, and during a medication pass observation, an LPN prepared and administered the heparin using an insulin syringe via subcutaneous injection in the abdomen. In a subsequent interview, the LPN stated that insulin syringes should only be used for insulin, but she used one for heparin because she had not been told to use other supplies and was unaware of other available injection supplies or their location. The DON later stated that insulin syringes are expected to be used only for insulin and confirmed that other injection supplies were available and that the insulin syringe should not have been used for the heparin injection.