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 a history of aggression and multiple behavioral health diagnoses was involved in a physical altercation with a CNA after staff failed to follow the resident's request and lacked appropriate de-escalation training. The incident resulted in the resident falling and sustaining an injury, highlighting the facility's failure to provide necessary behavioral health care and adequate staff training to manage aggressive behaviors.
A resident with severe cognitive impairment was physically restrained by CNAs during toileting after becoming combative, resulting in a skin tear and bruising. Facility policy prohibits rough handling and requires staff to manage behaviors without causing injury or distress, but staff held the resident's hands across the chest to prevent striking, which was confirmed through interviews and documentation.
A resident with severe mobility impairments was left unattended on the edge of a high bed while a CNA left the room to retrieve a mechanical lift and assistance. The resident subsequently fell to the floor, sustaining an abrasion. Staff interviews confirmed that proper procedures were not followed, as the resident should not have been left alone in this position.
A resident admitted with a left femur fracture and a surgical incision requiring wound care did not have their wound or necessary interventions documented in the baseline care plan. Although physician orders for wound care were present and staff were providing care, the omission was confirmed by the DON, who stated that all wounds and interventions should be included in baseline care plans.
A resident with a left leg fracture and surgical wounds had physician orders and assessments indicating the need for wound care, but the care plan did not include the required interventions for wound healing. The DON confirmed that while the wounds were noted in the care plan, the specific interventions were not documented as expected.
A resident with a healing open fracture of the left leg did not have sutures and staples removed as ordered by the physician. Instead, the removal was delayed until an outside wound clinic performed the procedure, as confirmed by the DON through record review and interview.
Staff documented the removal of sutures and staples from a resident's leg in the medical record, but wound photographs and outside clinic records later confirmed that the procedure had not been performed as documented. The DON verified that the documentation was inaccurate, resulting in incomplete and misleading records.
A resident with a skin impairment on the coccyx did not have wound care assessments or treatments documented in the medical record. Although the wound care nurse assessed and treated the area, she confirmed that she did not record her findings or interventions, and the DON verified that this documentation was missing.
Surveyors found that call lights were not accessible for three residents with significant mobility and cognitive impairments, with devices placed on the floor, under the bed, or at the foot of the bed. Staff interviews confirmed that call lights should be within reach, but observations showed this was not consistently done, increasing the risk of accidents and delayed response to resident needs.
A medication cart was left unlocked and unattended in a hallway, with the nursing computer open to the MAR and no staff present. An RN acknowledged leaving the cart unsecured while stepping into a resident's room, and the DON confirmed that all medication carts are expected to remain locked at all times. This failure to secure medications was not in accordance with facility policy.
Failure to Provide Necessary Behavioral Health Services and Staff Training
Penalty
Summary
The facility failed to ensure that a resident with a history of aggressive behaviors received the necessary behavioral health care and services to maintain their highest practicable well-being. The resident, who had diagnoses including cognitive communication deficit, depression, and a history of physically abusive behavior, was involved in an incident where he attacked a CNA, resulting in a fall and injury. The care plan for the resident identified aggressive and abusive behaviors, but interventions were limited to psychosocial therapy, 1:1 oversight as needed, and general support for anxiety and depression, without specific strategies for staff to manage or de-escalate aggressive incidents. On the night of the incident, the resident became upset after a wound dressing was changed and additional staff entered his room, which he perceived as threatening. Despite the resident's request for a particular CNA to leave, the CNA remained and attempted to provide care, leading to a physical altercation. The resident reported feeling provoked and acted in self-defense, resulting in a struggle and subsequent fall. Staff interviews confirmed that the resident was known for aggressive behavior and had a prior negative interaction with the CNA involved in the incident. The facility did not provide staff with de-escalation or specialized training for managing aggressive behaviors prior to the incident. Staff received only general abuse and neglect training upon hire, and there were no documented interventions or training in place to address the specific behavioral health needs of residents exhibiting aggression. This lack of appropriate staff training and tailored interventions contributed to the escalation of the situation and the resulting injury.
Inappropriate Use of Physical Restraint During Resident Care
Penalty
Summary
Facility staff failed to protect a resident with severe cognitive impairment, including diagnoses of unspecified dementia and Alzheimer's disease, from inappropriate use of physical restraint during care. According to interviews and record reviews, two CNAs attempted to assist the resident with toileting when the resident became combative, swinging arms and attempting to strike staff. In response, one CNA held the resident's hands across the chest to prevent hitting, which is considered a form of physical restraint. The facility's policy prohibits rough handling and requires staff to manage behaviors in a way that prevents injury, pain, or distress. Documentation revealed that following the incident, the resident was found to have a skin tear on the right lower abdomen and a large bruise on the right hand. Staff interviews confirmed that the restraint was applied during care, and the Assistant Director of Nursing acknowledged that staff should have stepped away and notified nursing staff rather than continuing care during combative behavior. The Administrator confirmed that restraining residents during care is not acceptable per facility expectations and policy.
Resident Fall Due to Inadequate Supervision During Transfer Preparation
Penalty
Summary
A deficiency occurred when a resident with significant physical impairments, including aphasia, hemiplegia, and contractures, was left unattended on the edge of a bed in a high position. The resident was dependent on staff for all activities of daily living and required a mechanical lift with two-person assistance for transfers. On the day of the incident, a CNA prepared the resident for transfer by placing the Hoyer lift sling under him but then left the room to retrieve the lift and another staff member, leaving the resident on the edge of the bed, which remained in a high position. During the CNA's absence, the resident fell from the bed and was found on the floor with an abrasion to the left lateral knee. Interviews with facility staff confirmed that the CNA did not follow proper procedures, as the resident should not have been left unattended, especially in a high bed position and near the edge. The resident's care plan specified that the bed should be in a low position and that all equipment should be ready prior to care. Staff acknowledged that the actions taken did not align with the resident's safety needs, particularly given his inability to control spastic movements.
Failure to Document Surgical Wound and Interventions in Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan that included all necessary information for providing care to a newly admitted resident with a surgical wound. Specifically, a resident admitted with a diagnosis of a left femur fracture and a surgical incision with staples did not have this wound or the required wound care interventions documented in their baseline care plan. Physician orders were in place for wound care, including cleaning the incision and ensuring a dressing was in place each shift until staple removal, but these interventions were not reflected in the baseline care plan. Interviews confirmed that staff were performing wound care and that the resident was scheduled for staple removal, yet the baseline care plan omitted any mention of the surgical wound or related interventions. The Director of Nursing acknowledged that staff were expected to document all wounds and interventions in baseline care plans, but this was not done for the resident in question.
Failure to Document Wound Care Interventions in Care Plan
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident admitted with a left fibula fracture and surgical wounds on the left knee and ankle. Record review showed that while physician orders and the MDS assessment documented the presence of surgical wounds and required wound care, the resident's care plan did not include the specific interventions ordered to treat these wounds. During an interview, the DON confirmed that although the care plan noted the existence of wounds, it lacked documentation of the interventions in place to promote healing, despite staff expectations to include all such interventions in the care plan.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of practice by not following a physician's order for wound care for one resident. The resident was admitted with a diagnosis of a left fibula fracture, specifically an open fracture type 1 or 2, and was progressing with routine healing. A physician's order dated 12/03/25 directed staff to remove the resident's sutures and staples from the left leg. However, staff did not carry out this order as required. Instead, the removal of the sutures and staples was delayed until the resident attended an outside wound care clinic, where the procedure was performed on 12/23/25. The Director of Nursing confirmed during an interview that staff were expected to follow physician's orders and acknowledged that the removal had not been completed by facility staff as ordered. This lapse was identified through record review and staff interview.
Incomplete and Inaccurate Medical Record Documentation for Wound Care
Penalty
Summary
Staff failed to ensure that medical records were complete and accurate for a resident who was admitted with a left fibula fracture and had an order for suture and staple removal from the left leg. The physician's order specified that the sutures and staples should be removed, and staff documented in the Treatment Administration Record that this procedure was completed as ordered. However, subsequent wound photographs taken several days later showed that both sutures and staples remained in place on the resident's leg. Further review of wound clinic documentation revealed that the sutures and staples were not actually removed until a later visit to an outside wound care clinic. During an interview, the Director of Nursing confirmed that staff had documented the removal of sutures and staples even though the procedure had not been performed. This inaccurate documentation resulted in incomplete and misleading medical records for the resident.
Failure to Document Wound Care Assessments and Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident with a skin impairment. Record review showed that the resident had an open area on the coccyx, and the medical provider was notified. The wound care nurse (WCN) was assigned to treat the area, and the plan was to follow up with daily assessments and treatment. However, there was no documentation by the WCN in the resident's medical record regarding her assessments or treatments of the wound. Interviews with staff confirmed the lack of documentation. The LPN stated that the WCN was treating the area, and the WCN herself acknowledged that she had not documented her assessments or treatments, despite assessing the wound and planning interventions. The Director of Nursing (DON) also confirmed that the WCN should have documented these observations, assessments, and treatments in the resident's medical record, but this was not done.
Call Lights Not Accessible for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for residents at risk for falls and injury, as required by their Call Light Policy. During observations, call lights for three residents with significant mobility and cognitive impairments were found out of reach: one call light was on the floor next to the bed, another was under the bed frame near equipment, and a third was placed on top of an air pump at the foot of the bed. These residents had diagnoses including repeated falls, muscle weakness, hemiplegia, hemiparesis, major depressive disorder, insomnia, lack of coordination, seizures, muscle spasms, and contractures, all of which increased their vulnerability to accidents if unable to summon assistance. Interviews with CNAs confirmed that call lights should not be placed on the floor or at the foot of the bed, and that they should be secured within the resident's reach to allow them to call for help when needed. The Director of Nursing also stated that all call lights should be clipped to the resident's beds to ensure accessibility. The failure to follow these procedures resulted in call lights being inaccessible for all three residents reviewed, creating the potential for accidents and delayed response to resident needs.
Unattended and Unlocked Medication Cart Found in Hallway
Penalty
Summary
A medication cart was observed on the 500 Hall with its drawers unlocked and the nursing computer open to the medication administration record (MAR), while no staff were present in the immediate area. This left the cart and its contents, including resident medications, unattended and accessible to residents passing through the hallway. The facility's Medication Storage and Security Policy requires all medications to be secured at all times, with medication carts locked when not in the direct possession of licensed staff, and controlled substances stored in a separately locked compartment. During interviews, a registered nurse (RN) admitted to leaving the cart unlocked while stepping into a resident's room, acknowledging that the cart contained narcotics in a locked box and other resident medications in the remaining drawers. The Director of Nursing (DON) confirmed the expectation that all medication carts remain locked at all times to prevent unauthorized access. The incident demonstrated a failure to follow facility policy and ensure the security of medications, including controlled substances.
Some of the Latest Corrective Actions taken by Facilities in New Mexico
- Re-educated center leadership on initiating investigations with immediate staff removal and resident protection protocols (K - F0610 - NM)
- Implemented abuse questionnaires for residents potentially affected to identify additional concerns during investigations (K - F0610 - NM)
Failure to Investigate and Prevent Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents, all of whom were reviewed for abuse. In one case, a cognitively intact resident reported that a CNA touched her anus during pericare and made her feel uncomfortable through unwanted physical contact and inappropriate language. The incident was reported to the Social Services Director, who informed the Administrator. The CNA was initially placed on leave, and an abuse questionnaire was conducted with other residents, but the investigation concluded the allegation was unsubstantiated, and the CNA was allowed to return to work with the condition of no further contact with the reporting resident. Another resident with moderate cognitive impairment reported that the same CNA attempted to sexually abuse her and her roommate. She described the CNA entering her room at night, attempting to touch her, and then moving to her roommate, where she witnessed inappropriate contact and heard inappropriate comments. Nursing notes documented these allegations, and a police report was filed. The roommate, who also had moderate cognitive impairment and a history of adult sexual abuse, was found fearful and confused, unable to recall the events or the CNA involved. Her husband was informed of an assault but was not given details. A fourth resident, cognitively intact, reported that the CNA made inappropriate comments and attempted to groom her, though she denied any inappropriate physical contact. She did not report these incidents to staff at the time. The Administrator stated that after the initial allegation, the CNA was suspended pending investigation, but the investigation relied on resident questionnaires and was deemed unsubstantiated, allowing the CNA to return to work. Only after further allegations did the facility bar the CNA from returning. The facility's investigation process did not thoroughly address or substantiate the multiple allegations, and steps to prevent further abuse were not adequately implemented.
Removal Plan
- Facility sent in late reportable for the second and third identified residents.
- Change in Condition with provider and responsible parties notified.
- Whole house abuse questionnaire completed with residents.
- Skin check for residents involved as appropriate.
- Psychiatric service referral for residents involved as appropriate.
- CNA in question was terminated.
- Center leadership staff will be re-educated on the following areas by Market Resource Nurse.
- Investigations start with removal of staff member and protection of resident.
- Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident.
- Individual self-reports to follow for any other residents who are identified during the questionnaires.
- Change in condition with provider and responsible party notification for those affected or impacted.
- Skin checks for residents involved as appropriate Social services to complete wellness checks and offer psychosocial support as appropriate.
- Psychiatric services referral for residents involved as appropriate.
Unsecured Medication Carts and Unattended Pre-Poured Medications
Penalty
Summary
Facility staff failed to properly secure and administer medications for all 112 residents listed on the census. Observations revealed that medication carts were left unlocked and unattended in hallways, providing unsupervised access to resident medications, including narcotic controlled substances. Additionally, staff were found to have pre-poured medications into unlidded cups and left them unattended on tables in resident care areas, with no licensed nurse present to supervise. These actions were in direct violation of the facility's medication administration policy, which requires medications to be prepared for one resident at a time, not to be pre-poured, and to remain secured and attended at all times. Interviews with staff confirmed these practices. A registered nurse acknowledged responsibility for keeping the medication cart locked and recognized that leaving it unsecured allowed unauthorized access to medications. A certified medication aide admitted to pre-pouring medications for multiple residents and leaving them unattended while assisting another resident, stating that this occurred once or twice a week. The aide also confirmed that the facility's policy prohibits pre-pouring and leaving medications unattended, and that staff are required to ask another qualified staff member to monitor medications if they must step away. The Director of Nursing confirmed that the facility does not permit pre-pouring medications or leaving them unsecured and unattended. She stated that only licensed individuals are responsible for medication administration and that certified nurse aides are not permitted to supervise medications. The DON acknowledged that leaving pre-poured medications unattended is unacceptable and creates significant risk, as staff would not know whose medications they were and residents or visitors could access them.
Removal Plan
- The identified CMA will not pass medications until further determination is made.
- The DON/designee checked all other medication carts to determine if there were any other pre-poured medications. No other instances of pre-poured medications were observed.
- The DON/designee checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- The DON/designee monitored residents on identified hall who received pre-poured medications, no concerns were identified. They were monitored for potential adverse medication reactions, such as a significant change in vital signs. No concerns were identified.
- Education was provided to all nurses and CMAs on-site regarding: Medications are to only be prepared for one resident at a time, using a 3-way-check (comparing the medication to the MAR and to the prescription label).
- No pre-poured medications are allowed.
- Medications are not to be left unsecured and unattended.
- Medication carts will be locked at all times when out of site or unattended.
- Nurses and CMAs that are coming in as scheduled, will receive education prior to passing any medications.
- Additional Nurses and CMAs that are not onsite will receive education via telephone and a signed acknowledgement of education will be obtained prior to their next working shift.
- Record review of new admissions audit to ensure accurate medication reconciliation, review and continuation of medications and treatments.
- Record review of staff signature sheets for checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- Interviews with nurses regarding in-services and on pre-pouring medication and leaving medications unsecure.
- Interview with the Administrator and DON regarding plan of removal, audits, and medication reconciliation processes.
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