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 with type 2 diabetes was found to have overgrown toenails and callused feet, with no evidence of toenail care or podiatry referral since admission. Staff confirmed that toenail care had not been provided and that a podiatrist was not available to the facility, resulting in a lack of appropriate foot care for the resident.
Staff failed to document required blood pressure and heart rate readings before administering certain medications to a resident with hypertension and atrial fibrillation, and entered an incorrect diagnosis on the medication administration record for another resident prescribed mirtazapine. The Director of Nursing confirmed these documentation errors, resulting in incomplete and inaccurate medical records.
A paper listing residents' names and vital sign readings was left face up on the nurses station countertop, exposing personal health information to unauthorized individuals. This was confirmed by a staff member and the DON, and had the potential to affect all residents on two halls.
The facility did not update care plans for two residents to reflect current information, including a change in discharge plans for one resident and the addition of psychotropic medications for another. The care plans lacked necessary updates and interventions, as confirmed by the DON.
A resident who needed partial to moderate assistance with personal hygiene was observed to have overgrown and jagged fingernails. The resident stated that staff had not offered to cut her fingernails and she did not have clippers to do it herself. A CNA confirmed the resident's fingernails had not been cut.
A resident with a history of dizziness, dementia, and osteoporosis experienced an unwitnessed fall, which was documented in progress notes and led to new physician orders for fall prevention and monitoring. However, the annual MDS assessment failed to record the fall, and the MDS Coordinator confirmed the inaccuracy during an interview.
A resident's oxygen cylinder was observed unsecured next to their recliner while not in use, contrary to facility policy requiring all oxygen tanks to be properly supported or chained. The DON confirmed that oxygen cylinders should not be stored unsecured in resident rooms, as this could lead to accidents.
A resident's code status was inconsistently documented, with the face sheet missing the information, hospital and NM MOST forms indicating DNR, and the care plan listing Full Code. A family member was told by a nurse that the resident was Full Code, despite prior DNR documentation. The DON confirmed the inconsistency and stated the facility presumes Full Code if not documented.
Staff left an electrical junction box and fire alarm control panel unsecured and accessible, with exposed wires in common areas. Electrical cords for a power wheelchair were left stretched across a hallway floor, creating a tripping hazard. In a resident's room, a large kitchen knife and an open can of WD-40 were found accessible. Facility policy required these hazards to be secured or removed to ensure resident safety, but these actions were not taken.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Failure to Provide Foot Care for Diabetic Resident
Penalty
Summary
Staff failed to provide appropriate foot care for a resident with type 2 diabetes mellitus. The resident was admitted with this diagnosis and, during observation, was found to have overgrown toenails and callused feet. The resident reported that staff had not offered to cut her toenails and that she had not seen a podiatrist since admission. Additionally, the resident stated she had lost a toenail, which was documented in a progress note, and was instructed to cleanse and dress the area until healed. Interviews with facility staff confirmed that the resident's toenails were long and had not been cut. Staff also acknowledged that the facility did not have a podiatrist available to provide foot care, and no referrals had been made for the resident to see a podiatrist until recently. Nursing staff indicated that residents' nails should be checked weekly, but this had not occurred for the resident in question.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
Staff failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses of hypertension and paroxysmal atrial fibrillation, physician orders required blood pressure and heart rate monitoring prior to administering medications such as metoprolol, lisinopril, and furosemide. However, staff did not document the required blood pressure or heart rate readings on the medication administration record (MAR) or in the vital signs section of the medical record on multiple occasions throughout August. The Director of Nursing confirmed that staff are expected to document these vital signs as indicated in the physician's orders, either on the MAR or in the vital signs section. For another resident admitted with a diagnosis of circadian rhythm sleep disorder, the MAR incorrectly listed the indication for mirtazapine as depression, while the psychiatric provider's note and the Director of Nursing confirmed the medication was prescribed for circadian rhythm disorder. The DON acknowledged that staff entered the order with the wrong indication. These documentation errors resulted in incomplete and inaccurate medical records for both residents.
Resident Health Information Left Unsecured at Nurses Station
Penalty
Summary
A deficiency occurred when a paper document containing residents' names and their vital sign readings was left face up on the nurses station countertop, making personal health information visible to unauthorized individuals. This was observed during a random facility check, and the presence of the document was confirmed by a staff member. The Director of Nursing also acknowledged that such information should be safeguarded and not left in plain view. The incident had the potential to affect all 38 residents residing on the East 1 and East 2 halls.
Failure to Update Care Plans with Current Resident Information and Medication Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information for two residents. For one resident, documentation showed that the resident expressed a desire to be discharged to an assisted living facility, and this was discussed with the guardian and during a care plan meeting. However, the resident's care plan continued to state that discharge was not expected and did not reflect the updated discharge plan or the resident's expressed wishes. For another resident, physician orders were in place for two psychotropic medications, trazodone and mirtazapine, prescribed for circadian rhythm disorder and depression, respectively. Despite these orders, the resident's care plan did not include any interventions or goals related to the use of these medications. The DON confirmed that the care plan lacked the required information for these medications and acknowledged that interventions and goals should have been included.
Failure to Assist with Personal Hygiene—Fingernail Care
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required partial to moderate help with personal hygiene. Record review showed the resident was admitted to the facility and required assistance, as documented in the most recent MDS assessment. During an observation, the resident's fingernails were found to be overgrown, jagged, and uneven from breaking off. The resident reported that staff had not offered to cut her fingernails and that she did not have clippers to do it herself. A CNA confirmed that the resident's fingernails were long and had not been cut.
Inaccurate MDS Assessment Following Resident Fall
Penalty
Summary
Facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident's admission record included diagnoses of dizziness, senile dementia, and osteoporosis. On 03/18/25, the resident experienced an unwitnessed fall, which was documented in progress notes and resulted in new physician orders for fall prevention, monitoring for injuries, and neurological checks. Despite this incident, the resident's annual MDS assessment indicated that no falls had occurred since admission or the prior assessment. During an interview, the MDS Coordinator confirmed that the MDS was inaccurate because it did not reflect the documented fall.
Failure to Secure Oxygen Cylinder
Penalty
Summary
The facility failed to secure an oxygen cylinder for one resident, resulting in the oxygen tank being left unsecured next to the resident's recliner while not in use. According to the facility's oxygen safety policy, all oxygen cylinders, whether full, empty, connected, or unconnected, must be properly chained or supported in racks, sturdy portable carts, or approved stands to prevent them from falling. Observation confirmed the unsecured oxygen tank, and during an interview, the DON acknowledged that portable oxygen containers should not be stored unsecured in resident rooms, as this could cause an accident.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently and accurately documented across all medical records. Upon review, the resident's face sheet did not include any code status, while the hospital discharge documentation and the New Mexico Medical Orders for Scope of Treatment (NM MOST) form both indicated a Do Not Resuscitate (DNR) status. However, the resident's care plan listed a Full Code status. During the admission process, a family member was informed by a nurse that the resident was a full code, despite the family member's knowledge of a DNR status from the hospital. The Director of Nursing confirmed that the facility presumes full code status if no documentation is present and acknowledged the inconsistency in the resident's records.
Unsecured Electrical Panels, Tripping Hazards, and Unsafe Items in Resident Areas
Penalty
Summary
Staff failed to maintain a safe environment free from accident hazards, as evidenced by several observations throughout the facility. An unsecured electrical junction box with exposed wires and circuit boards was found within reach of residents in a hallway, and staff were not present in the area. Multiple electrical cords, including a power cord and a coaxial cable for a power wheelchair, were left unattended and stretched across the hallway floor, creating a tripping hazard. Additionally, the fire alarm control panel in the main hallway was observed open with exposed wires and components, accessible to residents and without staff supervision. In a resident's room, a large kitchen knife was found on a desk and an open can of WD-40 was on the nightstand. The resident stated the knife was used to cut fruit and the WD-40 was for wheelchair maintenance. Facility staff, including the ADON and Maintenance Director, confirmed that the fire alarm panel, electrical boxes, and hazardous items such as knives and chemicals should be secured at all times to prevent resident injury or tampering. These conditions were not in accordance with the facility's policy on hazardous areas, devices, and equipment.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Some of the Latest Corrective Actions taken by Facilities in New Mexico
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