Citations in New Mexico
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Mexico.
Statistics for New Mexico (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Mexico
A resident was discharged, but the facility’s business office failed to ensure the resident was only financially liable for services actually rendered and did not issue a required refund within the mandated timeframe. The Business Office Manager confirmed that the facility received payment for a period after discharge that it should not have received and that the refund for the overpayment was delayed for several months before being mailed.
The facility failed to ensure meals were palatable and served at an appetizing temperature, as multiple residents reported that their food was consistently or often cold, sometimes arriving after long delays and no longer warm enough to enjoy. One resident described the food as horrible and stopped requesting reheating because it did not improve the temperature, while another reported inconsistent meal temperatures. During a lunch observation, plates for two residents were cool to the touch. The Dietary District Manager acknowledged awareness of complaints about cold food, and the Administrator confirmed awareness of ongoing food temperature problems despite the use of plate bases and warmers.
A resident was admitted with an unstageable pressure ulcer documented on the Admission MDS, along with a need for pressure ulcer/injury care, but the baseline care plan created within 48 hours did not include the pressure ulcer or the need for wound care. During interview, the DON confirmed the omission and stated the expectation that nurses care plan wounds and necessary wound care within the first 48 hours of admission.
Surveyors found that two residents with documented unstageable pressure ulcers and identified needs for pressure ulcer care on their admission MDS and Care Area Assessments did not have corresponding pressure ulcer or wound care interventions included in their comprehensive care plans. One resident’s care plan lacked any pressure ulcer component despite multiple unstageable and deep tissue injuries noted on admission, and another resident’s care plan omitted pressure ulcer care until it was added at a later date. The DON acknowledged that the comprehensive care plans for these residents did not address their pressure ulcers or wound care needs, contrary to facility expectations.
Surveyors found that wound care orders for two residents’ buttock wounds were not accurately documented on the Treatment Administration Record (TAR). One resident’s ordered daily wound care was missing documentation on multiple specific days, and another resident’s ordered wound care lacked documentation over an extended period. The Wound Care Nurse reported that she completed the ordered treatments on numerous dates but did not record them on the TAR, sometimes relying on the unit nurse to document instead. This resulted in incomplete and inaccurate medical records related to wound care.
The facility failed to accurately complete PASARR Level I screenings for multiple residents with documented mental health diagnoses, including major depressive disorder, depression, and anxiety disorders. Despite these diagnoses being listed on admission face sheets, staff marked on the PASARR forms that the residents did not have mood, anxiety, psychotic, or related mental health conditions. The SSD reported there was no systematic process to review incoming PASARRs for accuracy and acknowledged that her department had not been reviewing these screenings, resulting in multiple inaccurate PASARRs for residents requiring mental health-related assessment.
Staff failed to maintain a safe oxygen storage area on one unit when the oxygen storage room door lock was nonfunctional, allowing the door to be opened without an access code, and portable O2 cylinders were observed sitting on the floor instead of in the designated cylinder rack. Facility policy required oxygen cylinders to be secured in a cart or bracket and stored in clean, dry locations. The Central Supply Manager acknowledged that all oxygen equipment must be stored in proper areas for safety and that improper storage could create a hazard, and the Administrator stated the oxygen storage room was expected to remain locked at all times when not in use but was unaware the keypad lock was not working.
A resident with moderate cognitive impairment reported that a CNA providing personal care intentionally struck her with a small pillow and then a flowered blanket, continuing even after she told the CNA to stop and also hitting items on her wall. The resident filed a grievance describing this abusive behavior. Record review confirmed the grievance details, and the facility’s investigation substantiated that the physical abuse occurred, with leadership acknowledging that the CNA’s actions were inappropriate.
Facility staff failed to complete an accurate discharge MDS for a resident when the discharge destination was left blank. The resident, who had diagnoses including Guillain-Barre syndrome, epilepsy, and depression, became unable to transfer out of bed and was transported by ambulance to a hospital for evaluation after a change in condition. Documentation in the medical record, including a change in condition form and progress note, showed the resident was sent to the hospital, and the DON confirmed the resident had been scheduled for discharge that day. The MDSC, who was responsible for the assessment, acknowledged that the resident was discharged to the hospital and that the discharge MDS was inaccurate because the discharge destination was not coded.
The facility failed to conduct and document effective discharge planning and to include specific discharge-related interventions in care plans for three residents. One resident with a goal to move to assisted living had no documented IDT discharge planning meetings and no care plan interventions to support that goal, as confirmed by the POA and record review. Another resident’s plan to return home with home health lacked documented, specific interventions in the care plan. A third resident was told coverage was ending and that continued stay would incur daily charges, and was discharged home without medications, DME, or information on home health, community providers, or follow-up care; there was no documentation of discharge planning, attempts to arrange home health or DME, or a post-discharge plan of care. The administrator acknowledged that discharge planning was expected to begin at admission, involve IDT meetings with residents/representatives, and be documented in the record, but confirmed this had not occurred for these residents.
Failure to Timely Refund Overpayment After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a discharged resident was only held financially liable for services rendered and to provide timely refunds of overpayments. Record review of one resident’s electronic health record showed the resident was discharged on 10/22/25. During an interview on 02/26/26, the Business Office Manager confirmed that this resident was owed a refund for October and November 2025, that the facility received a payment in November that it should not have received, and that the facility did not issue the October refund within 30 days of discharge as required. The Business Office Manager further stated that the refund was not mailed until 02/20/26, approximately 120 days after the resident’s discharge, demonstrating that the resident was not refunded all monies due within the required timeframe.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable and served at an appetizing temperature for all six residents reviewed, with the potential to affect all 128 residents in the facility. Multiple residents reported that their meals were consistently or often cold when they were supposed to be hot. One resident stated they ate only what they could tolerate because the food often arrived too cold to enjoy. Another resident reported that room trays sometimes took a long time to reach the rooms, and others stated their meals were often not warm enough or were already cold by the time the tray reached them. One resident described the food as horrible and said they no longer asked to have it warmed up because it had not helped in the past, and another resident reported that meal temperatures were inconsistent, with some meals arriving cold and others not. During observation of a lunch meal tray delivery to one unit, the plates for two of the reviewed residents were noted to be cool to the touch, supporting the residents’ reports of inadequate food temperatures. In interviews, the Dietary District Manager acknowledged being aware of residents’ complaints about cold food served at the facility. The Administrator stated that the facility used plate bases and plate warmers to help keep hall tray meals warm and acknowledged awareness of a problem with food temperatures. These interviews and observations demonstrate that the issue of cold meals was known to facility leadership and dietary management while residents continued to receive meals that were not served at an appetizing temperature.
Failure to Accurately Care Plan Admission Pressure Ulcer Within 48 Hours
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident, resulting in omission of critical wound information. Record review showed the resident was admitted on an unspecified date, and the Admission MDS documented that the resident had one unstageable pressure ulcer present on admission and required pressure ulcer/injury care. However, review of the resident’s baseline care plan, dated 02/19/26, revealed that staff did not document the presence of the pressure ulcer or the need for wound care. In an interview on 02/20/26 at 1:31 PM, the DON confirmed that the resident’s care plan did not indicate the pressure ulcer or wound care needs and stated that her expectation was for nurses to care plan wounds and necessary wound care within the first 48 hours of admission. This deficient practice could likely result in residents not receiving appropriate care and may place residents at risk of an adverse event or worsening of their condition after admission.
Failure to Develop Comprehensive Care Plans for Residents With Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the development and implementation of accurate, person-centered comprehensive care plans related to pressure ulcers for two residents. For one resident, the admission MDS dated 01/15/26 documented one unstageable pressure ulcer present on admission and two additional unstageable pressure injuries presenting as deep tissue injuries, also present on admission. The Care Area Assessment dated 01/21/26 indicated a need for pressure ulcer care. However, review of this resident’s care plan dated 01/16/26 showed that no care plan addressing pressure ulcers or the need for wound care had been developed. For the second resident, the admission MDS documented one unstageable pressure ulcer present on admission, and the Care Area Assessment dated 01/06/26 indicated a need for pressure ulcer care. The resident’s care plan, initiated on 12/28/25, did not include a care plan for pressure ulcers at that time; a pressure ulcer care plan was not added until 02/20/26. During an interview on 02/20/26 at 1:33 PM, the DON confirmed that comprehensive care plans for both residents did not include plans for their pressure ulcers and the need for wound care, despite the facility’s expectation that staff complete comprehensive care plans to include pressure ulcers and wound care needs.
Incomplete and Inaccurate Wound Care Documentation on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to wound care treatments for two residents. For one resident with a physician’s order dated 01/15/26 for daily wound care to the right buttock using normal saline, Medihoney, calcium alginate gauze, and a silicone bordered dressing, the Treatment Administration Record (TAR) for January 2026 showed no documentation that wound care was completed on 01/19/26, 01/21/26, and 01/23/26. For another resident with a physician’s order dated 01/01/26 for wound care to bilateral buttocks, including cleansing with normal saline, application of Sureprep to surrounding tissue, Medihoney to the wound bed, and coverage with a sacral silicone bandage, the January 2026 TAR contained no documentation of wound care from 01/02/26 through 01/23/26. During an interview on 02/20/26, the Wound Care Nurse stated she worked Monday through Friday and completed all wound care on those days. She reported that she did perform wound care for the first resident on 01/19/26, 01/21/26, and 01/23/26 but did not document these treatments on the TAR. She also stated she completed wound care for the second resident on 01/01/26, 01/02/26, 01/05/26 through 01/09/26, 01/12/26 through 01/16/26, and 01/19/26 through 01/23/26, but again did not document these treatments on the TAR. The Wound Care Nurse indicated that sometimes the unit nurse documented completion of wound care on the TAR, and acknowledged she should ensure that either she or the unit nurse documented the wound care as completed. The survey findings state that this failure to accurately document wound care had the potential to negatively impact the care staff provide due to inaccurate records.
Inaccurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I screenings for multiple residents with documented mental health diagnoses. Record review showed that several residents were admitted with diagnoses such as major depressive disorder, depression, and anxiety disorders, yet their PASARR Level I forms indicated that they did not have mood, anxiety, or other qualifying mental health conditions. For example, one resident admitted with major depressive disorder had a PASARR Level I dated the same day of admission that documented no mood, panic, anxiety, personality, psychotic, depression, or substance-related disorders. Similar discrepancies were identified for additional residents. Another resident admitted with major depressive disorder had a PASARR Level I completed the day prior to admission that incorrectly indicated no mood or depression-related diagnoses. Residents with documented anxiety disorders also had PASARR Level I screenings that stated they did not have anxiety, mood, or related mental health conditions. Multiple residents with diagnoses of depression or major depressive disorder had PASARR Level I screenings completed on or near their admission dates that failed to acknowledge these conditions, instead marking that no such mental health diagnoses were present. During an interview, the Social Services Director reported that the facility did not have a systematic process in place to review incoming PASARRs as part of the admission screening process. The Social Services Director stated she had only recently been informed that reviewing resident PASARRs was the responsibility of her department and acknowledged that PASARRs were not being reviewed for accuracy. She confirmed that the PASARRs for all identified residents were inaccurate and stated that they should have reflected the residents’ documented mental health diagnoses.
Failure to Secure Oxygen Storage Room and Properly Store Oxygen Cylinders
Penalty
Summary
Facility staff failed to maintain a safe oxygen (O2) storage environment on the 200-unit by not securing the oxygen storage room and not properly storing oxygen cylinders. Record review of the facility’s Oxygen Administration Policy dated 06/2020 showed that oxygen cylinders were required to be secured in a cylinder cart or bracket at all times and stored in clean, dry locations. On observation, the oxygen storage room keypad door lock on the 200-unit was without power, nonoperational, and its screen remained blank and did not activate when touched, allowing the door to be opened without entering an access code. Additional observation showed portable medical oxygen cylinders sitting on the floor instead of being stored in the designated oxygen cylinder rack. In interviews, the Central Supply Manager stated that all oxygen equipment, including portable oxygen tanks, must be stored in proper storage areas for safety and that improper storage could create a hazard, and the Administrator stated the oxygen storage room should remain locked at all times when not in use and acknowledged she was not aware the keypad lock was not functioning and that the door could be opened without a code. No specific residents or their medical histories were identified in the report; the deficiency pertained to the general safety of the oxygen storage area accessible to residents, staff, and the public.
Failure to Protect a Resident From Physical Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by staff during the provision of personal care. The resident, a long-term resident with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, reported that on a specific date a CNA providing direct care in her room intentionally struck her with her small pillow and then with a flowered blanket. According to the resident’s grievance and subsequent interview, she told the CNA to stop, but the CNA continued by hitting her with the blanket and also striking personal items hanging on her wall, attempting to knock her belongings off. The resident stated she felt upset by the incident and filed a grievance with the facility. Record review confirmed the resident’s long-term status in the facility and documented her grievance alleging that the CNA slapped her with a pillow and blanket. The facility’s investigative report, as referenced in the record review, substantiated that the abuse occurred. Interviews with the DON and the Administrator confirmed their awareness of the grievance and that the involved CNA was an agency staff member. The DON stated that the CNA should not have struck the resident with the pillow and blanket, and the Administrator stated that, although there were no witnesses, he believed the resident’s account and noted that she did not have cognitive deficits and was a strong self-advocate. The core deficiency is that facility staff, specifically an agency CNA, engaged in intentional physical contact with the resident using a pillow and blanket in a manner characterized as rude and abusive while providing care.
Inaccurate Discharge MDS Due to Omitted Discharge Destination
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the discharge MDS did not include the resident’s discharge destination. The resident had been admitted with Guillain-Barre syndrome, epilepsy, and depression, and was later unable to transfer out of bed and was sent to the hospital via ambulance for evaluation after experiencing abdominal pain. Record review showed a Change in Condition form and progress note documenting the transfer to the hospital, and the DON stated the resident had been scheduled for discharge on the same day the resident was sent to the hospital. However, the discharge MDS for that resident, completed by the MDS Coordinator, was left with the discharge destination field blank, despite the MDSC acknowledging that the resident was discharged to the hospital and that the assessment was therefore inaccurate. This deficiency was identified through record review of the face sheet, Change in Condition form, progress note, and discharge MDS, as well as interviews with the DON and the MDSC, who confirmed that the discharge destination should have been coded and that it was her responsibility to complete accurate MDS assessments.
Failure to Conduct and Document Effective Discharge Planning and Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process and to ensure care plans reflected specific discharge interventions for three residents. For one resident admitted in early February, the care plan documented a goal to discharge to an assisted living facility, but there were no specific interventions listed to help achieve this goal. The resident’s POA reported that no meetings had been held with her to discuss what interventions were being implemented to support the planned discharge. The medical record contained no documentation of discharge planning meetings with the IDT, the resident, or the resident’s representative. A second resident was admitted and later discharged home with home health services identified as the discharge plan. However, the care plan did not include specific interventions to assist the resident in meeting this discharge goal. There was no indication in the cited documentation that the comprehensive care plan or discharge plan had been updated with treatment preferences and needs related to the discharge. A third resident was admitted and later discharged home after Medicare Part A coverage ended. The resident’s family member reported being informed by a social services clerk that Medicare coverage would end on a specific date and that continued stay would cost a daily rate, and another staff member told her the resident had to leave by noon on the last covered day to avoid charges. The family member stated there had been no meetings with her or the resident to discuss the discharge or interventions needed for a safe discharge, and that the resident was discharged without medications, DME, home health information, community provider information, or follow-up appointment information. The care plan listed a goal to discharge home with home health services but lacked specific interventions, and the medical record did not contain documentation of discharge planning, attempts to obtain home health or DME, or a post-discharge plan of care. The administrator confirmed the absence of documented discharge planning meetings and care plan updates for all three residents and was unable to determine whether discharge plans had been discussed with the third resident or his family member.
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