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
The facility did not employ a Certified Dietary Manager or equivalent qualified staff to oversee food and nutrition services for approximately one month. Dietary staff and the administrator confirmed the absence of a dietary manager, and the dietitian was only present one day per week, affecting all residents receiving meals from the kitchen.
The facility did not maintain sanitary food storage practices or monitor refrigerator and freezer temperatures in the nourishment room. Expired food items and improperly stored sandwiches without expiration dates were found, and staff interviews revealed uncertainty and lack of oversight regarding temperature checks and food expiration monitoring.
Staff failed to maintain complete and accurate medical records for two residents, including missing documentation of pain location and effectiveness of pain medication for one resident, and failure to update a diagnosis of major depressive disorder in the EMR for another, as confirmed by the DON.
The facility did not ensure that required Effective Communication training was completed by a RN, an LPN, and a CNA, as shown by missing completion dates in their training records and confirmed by the Human Resource Manager.
Several staff members, including RNs, an LPN, and a CNA, did not complete required training on resident rights, as confirmed by record review and the Human Resource Manager. This deficiency was identified during a review of staff training records.
Mandatory QAPI training was not completed by a registered nurse, an LPN, and a CNA, as confirmed by review of training transcripts and staff interviews. The Human Resource Manager verified that these staff members had not fulfilled the required training.
Two staff members did not complete required annual infection control training, as confirmed by review of training records and facility staff. This failure occurred despite the facility's policy mandating yearly infection control education for all staff.
A CNA did not complete the required 12 annual in-service training hours, with only 1 hour documented for the year, as confirmed by the HR Manager.
Surveyors identified that three residents had inaccurate MDS assessments. One resident was incorrectly documented as having received insulin instead of semaglutide, another had restorative nursing services omitted from their assessment despite receiving them, and a third was inaccurately reported as having a stage 2 pressure ulcer when only a blister and cellulitis were present. These inaccuracies were confirmed through record review and staff interviews.
Staff did not notify the provider when a resident with hypertension had repeated episodes of high blood pressure and low pulse outside of physician-ordered parameters, and continued to administer amlodipine without contacting the physician as required. The DON confirmed that staff failed to follow the notification protocol for abnormal vital signs.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) or an individual with equivalent qualifications to oversee the food and nutrition service, as required by regulations. Interviews with dietary staff revealed that the facility had not had a dietary manager for approximately one month, and staff were unsure if a dietitian was present. The administrator confirmed that the dietitian only worked at the facility one day per week and that there had been no dietary manager since a specific date. This deficiency potentially affected all 29 residents who consumed food prepared in the facility's kitchen, as identified by the resident matrix. The absence of a qualified dietary manager or equivalent staff meant that the facility did not meet the regulatory requirements for food service management and oversight during the period in question.
Failure to Maintain Sanitary Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in accordance with professional standards for all 29 residents who consumed food or drinks from the nutrition refrigerator or freezer. Observations revealed that there was no temperature log for the refrigerator or freezer in the nourishment room, and staff were unsure of the location or existence of such logs. Interviews with nursing and dietary staff confirmed that kitchen staff were responsible for monitoring temperatures, stocking, and removing expired items, but had not been checking or recording temperatures for the nutrition room refrigerator and freezer. Further inspection of the nutrition refrigerator and freezer found expired food items, including a sandwich and a bag of shredded cheese, as well as several individually packaged peanut butter and jelly sandwiches without expiration dates. These sandwiches, which were labeled to be stored frozen until served, were found in the refrigerator instead of the freezer. The DON confirmed the presence of expired items, lack of expiration dates, improper storage of food items, and uncertainty regarding temperature monitoring responsibilities.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
Facility staff failed to ensure that medical records were complete and accurate for two residents. For one resident, physician orders indicated acetaminophen was to be administered as needed for pain, and the medication administration record (MAR) showed multiple instances where the medication was given along with the resident's reported pain level. However, staff did not consistently document the specific reason for administration, the location of the pain, or whether the medication was effective, except for one instance where throat pain was noted. The Director of Nursing (DON) confirmed that staff did not document the required information and acknowledged that such documentation is expected to help guide further treatment decisions. For another resident, the admission record did not list any mental health diagnoses, despite physician orders and provider progress notes indicating a diagnosis of major depressive disorder (MDD) and ongoing orders for mirtazapine to treat depression and appetite. Staff failed to update the resident's electronic medical record (EMR) to include the diagnosis of MDD, as confirmed by the DON. The expectation was that all new diagnoses should be promptly updated in the EMR, but this was not done for this resident.
Failure to Ensure Completion of Effective Communication Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed the mandatory Effective Communication training, as evidenced by the absence of completion dates on the online training transcripts for three staff members: a registered nurse, a licensed practical nurse, and a certified nursing assistant. Record reviews confirmed that these staff members had not completed the required training. During an interview, the Human Resource Manager verified that the Effective Communication Training had not been completed for these individuals. This deficiency was identified through both documentation review and staff interview, indicating a lapse in the facility's training program for direct care staff regarding effective communication.
Failure to Provide Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide resident rights training to four out of five sampled staff members, including registered nurses, a licensed practical nurse, and a certified nursing assistant. Record reviews showed that these staff members did not complete the required training on resident rights, which is intended to help staff promote and protect the rights of each resident and emphasize individual dignity and self-determination. During an interview, the Human Resource Manager confirmed that these staff members had not completed the training. No information about residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Ensure Completion of Mandatory QAPI Training by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed the mandatory Quality Assurance and Performance Improvement (QAPI) training. Record reviews of employee training transcripts revealed that a registered nurse, a licensed practical nurse, and a certified nursing assistant had not completed the required QAPI training. This was confirmed during an interview with the Human Resource Manager, who acknowledged that these staff members had not fulfilled the training requirement. The deficiency was identified through a review of training records and staff interviews.
Failure to Ensure Annual Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure that all required staff completed annual infection control training as part of its infection prevention and control program. Record review showed that one certified nursing assistant completed infection control training in November 2022 and one registered nurse completed the training in December 2023, but neither had completed the required training for the current year. During an interview, the Human Resource Manager confirmed that these staff members had not fulfilled the annual training requirement for 2025, despite the facility's policy that mandates yearly completion of infection control training. This lapse in training was identified through review of staff training records and confirmed by facility staff, indicating that the infection prevention and control program's standards, policies, and procedures were not fully implemented for all staff as required.
CNA Did Not Receive Required Annual In-Service Training
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) received the required minimum of 12 in-service training hours within a year of their hire date. Record review showed that the CNA, hired on 07/18/11, had only completed 1 in-service training hour during the review period. This was confirmed by the Human Resource Manager during an interview, who acknowledged that the CNA did not meet the annual in-service training requirement. The report specifically notes the lack of adequate training hours for this CNA, with no mention of other staff or residents directly affected in the findings.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented that the resident received an insulin injection, when in fact the resident only received a semaglutide injection and no insulin. This was confirmed by both the Medication Administration Record (MAR) and the MDS Coordinator. For another resident, the MDS assessment failed to reflect that the resident had received Restorative Nursing Program (RNP) services, including both active and passive range of motion exercises, within the seven days prior to the assessment, despite documentation showing these services were provided. The MDS Coordinator acknowledged that these services should have been included in the assessment. Additionally, a third resident's MDS assessment inaccurately indicated the presence of a stage 2 pressure ulcer, when the resident actually had an open blister and cellulitis on the lower left leg, but no pressure wounds. This discrepancy was confirmed through review of the skin assessment, physician's orders, and interview with the MDS Coordinator. In each case, the inaccurate MDS assessments were identified through record review and staff interviews, demonstrating a failure to accurately assess and document the residents' conditions and care provided.
Failure to Notify Provider of Abnormal Vital Signs
Penalty
Summary
Facility staff failed to notify the physician of abnormal vital signs for a resident with a diagnosis of essential hypertension. According to physician orders, staff were required to hold amlodipine and call the physician if the resident's systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) was less than 50, or pulse was less than 50. Additionally, staff were to administer the medication and call the physician if SBP was greater than 180, DBP was greater than 100, or pulse was greater than 100. Despite these clear parameters, staff documented multiple instances where the resident's SBP exceeded 180 and pulse was below 50, yet still administered amlodipine and did not notify the physician as required. Review of the Medication Administration Record (MAR) for April and May 2025 showed repeated occurrences of elevated blood pressure and low pulse readings, with no corresponding documentation of physician notification. Progress notes for March and April 2025 also lacked evidence of provider notification regarding these abnormal findings. The Director of Nursing confirmed that staff did not follow the order to notify the physician when the resident's blood pressure was elevated or pulse was low.
Some of the Latest Corrective Actions taken by Facilities in New Mexico
- The facility revised the resident's care plan to include 15-minute observations, conducted safety surveys with residents and staff, provided staff education on recognizing and reporting inappropriate behaviors, and implemented ongoing monitoring for residents displaying such behaviors. (K - F0600 - NM)
- The facility conducted a full abuse investigation, educated staff on abuse policies, and implemented immediate measures per the facility's Suicide Threats Policy for residents expressing suicidal ideation. (J - F0600 - NM)
- A new process was implemented to identify residents affected by abuse allegations, ensuring all residents are interviewed, especially those with lower cognitive abilities. Staff were educated on performing thorough investigations and the decision-making process regarding staff involved in abuse allegations. (K - F0610 - NM)
Failure to Protect Residents from Inappropriate Behavior
Penalty
Summary
The facility failed to protect residents from abuse, specifically failing to prevent a resident with a history of sexually inappropriate behavior from engaging in such actions. This resident, who had diagnoses including vascular dementia and cerebral infarction, was not adequately monitored or managed, leading to multiple incidents where he touched other residents without consent, entered their personal spaces unclothed, and made inappropriate comments. Despite having a care plan that initially addressed these behaviors, the interventions were removed prematurely, and staff failed to document or implement strategies to prevent further incidents. Several residents reported feeling unsafe due to the actions of this resident. One resident, with a history of PTSD and hallucinations, reported being touched on the leg, which led to her feeling unsafe and experiencing hallucinations about the resident entering her room. Another resident, with moderate cognitive impairment, was subjected to inappropriate sexual comments, which she did not hear, but staff failed to take appropriate action to monitor the resident making these comments. Additionally, a resident with severe cognitive impairment was touched on the thigh, and although her power of attorney was informed, the facility did not take sufficient steps to prevent recurrence. The facility's staff, including CNAs and RNs, were not adequately informed or instructed to monitor the resident's behavior, leading to repeated incidents. Interviews with staff revealed a lack of awareness and documentation regarding the resident's inappropriate behaviors, and the facility's administration did not consider the incidents to be sexual in nature, despite evidence to the contrary. This lack of appropriate response and monitoring resulted in a failure to protect residents from potential harm and distress.
Removal Plan
- The current care plan was revised to observe/monitor behaviors of touching. Resident #24 was immediately placed on 15-minute observations. Then, every shift thereafter, when behavior resolves 15-minute safety check will resolve.
- Safety Surveys were conducted to ask all residents and nursing staff employees if they felt unsafe around Resident #24.
- Education has been provided to staff: To increase staff awareness of when an event occurs related to inappropriate sexual comments and/or behavior; the staff will communicate during daily huddles. Additional education provided include: Abuse and Neglect; 15-minute Safety Checks during a new event; then every shift for residents identified to have a pattern of inappropriate behaviors until resolved. Know your Resident - which includes the process for reviewing the pattern of current and past behaviors, and interventions in the Care Plan with all staff and new employees. Shift huddle handoff will include not only medical report but also behavior changes and or concerns.
- On-Going Monitoring: New events will require 15-minute checks for inappropriate behaviors. After 15 minutes checks have concluded, checks will be every shift for those residents that have a pattern of inappropriate behavior or show signs of behavioral escalation.
- CNA's making the 15-minute observation checks will immediately report to the charge nurse any changes in behavior or inappropriate sexual remarks or actions. For residents that have a history of behavioral issues, after the 15 minute checks have expired, the behavioral monitoring will occur every shift. Any changes and or escalation in behavioral will be reported.
- Attempts are made to provide education on care plan and current interventions to Resident #24. However, due to BIMS score of 3.0, the resident does not comprehend the education.
- The Charge nurse is to verify every shift with the CNA assigned of the 15-minute observations. Then every shift thereafter.
- All resident care plans have been updated to address observation and monitoring of the encouraging all residents on the reporting of any unwanted pilfering/physical contact, including verbalizations that maybe offensive from any other resident.
- If an event occurs going forward that involves inappropriate sexual comments and/or gestures, the resident will immediately be placed on 15-minute observation checks and the observation checks are documented for the established timeframe. The care plan will be updated to reflect the interventions put in place.
Failure to Enforce Smoking Policies and Supervision
Penalty
Summary
The facility failed to implement adequate safety measures to prevent accidents related to smoking among residents. The facility's policies and procedures regarding the storage of smoking materials were not enforced, and residents were not properly assessed for safe smoking practices. The designated smoking area was not adequately supervised, leading to residents keeping smoking materials on their person and smoking in unauthorized areas, including their rooms. This lack of supervision and enforcement of smoking policies placed residents at risk of burns and severe injury. One resident, who was cognitively intact but had a history of unsafe smoking practices, was found smoking in her room despite being on continuous oxygen therapy. The resident's smoking materials were not stored at the nurse's station as required, and she was able to keep cigarettes and a lighter in her room. Staff interviews revealed that residents, including this one, often kept their smoking materials on their person, and the facility's policy of storing these materials at the nurse's station was not followed. The Director of Nursing (DON) and other staff members were aware of these violations but did not take appropriate action to address them. Other residents were also found to be non-compliant with the smoking policy, keeping their smoking materials with them and smoking in unauthorized areas. Staff interviews indicated a lack of awareness and enforcement of the facility's smoking policies. The DON and Administrator were not informed of incidents involving residents smoking in their rooms or keeping smoking materials, and no incident reports were generated for these violations. This systemic failure to enforce smoking policies and supervise residents adequately led to a significant risk of accidents and injuries.
Removal Plan
- Resident #78's smoking assessment was updated to ensure accuracy and has been identified as a supervised smoker. Her care plan was updated to reflect this.
- Resident #78's room and person were observed for smoking material and none was found, as she was compliant in providing her smoking material to the staff when asked.
- Resident #78 was re-educated on the smoking policy and agreed to follow the policy. Family was notified of the policy as well.
- Resident #78 was given a behavioral contract. If she does not adhere to the policy, she will be given a 30-day discharge notice.
- All residents who smoke were assessed by licensed nursing staff with no injury identified related to smoking.
- The Administrator/designee began individual meetings with smokers for the identified residents who smoke at the center to review the smoking policy/process, and/or initiate behavioral contract.
- The Administrator/designee compiled a list of residents who smoke at the center to be placed at the nurses station and will be updated as needed.
- A whole house sweep of resident smoking materials was completed by the Administrator/designee to ensure no items are observed in the resident rooms or observed on the resident and will be obtained if found, or a behavioral contract will be initiated if they do not agree to give up items.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure wounds for two residents. For one resident, the facility did not timely identify a new wound, monitor changes, provide daily treatments as ordered, or notify the physician of the wound's worsening condition. This resident was admitted with a risk for pressure ulcers and later developed an unstageable pressure ulcer on the left heel, which was not properly documented or treated, leading to a below-the-knee amputation. The facility's wound care nurse (WCN) acknowledged that the resident's left heel pressure ulcer deteriorated over time, and there was a lack of consistent weekly skin evaluations. The WCN was also required to work the floor due to staffing shortages, which contributed to the oversight. The resident's medical records did not reflect any updates or changes to the wound care orders, and the wound care was not consistently provided as per the physician's orders. For the second resident, the facility failed to complete and document weekly skin evaluations. The resident had an unstageable pressure ulcer on the right heel, and there was a significant gap between skin evaluations conducted by the WCN. The facility's failure to conduct regular skin assessments and document the condition of the resident's wounds contributed to the deficiency.
Removal Plan
- The nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed.
- Nurses will be educated on completion of skin assessments on admission and weekly per schedule.
- Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds).
- Nurses will be educated on wound processes which include the DIMES (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, wound Edge preparation and wound depth), timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds.
- CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes) and stop and watch.
Inadequate Staff Competency Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies to provide adequate care for two residents, resulting in severe consequences. One resident, who was dependent on staff for all activities of daily living due to conditions such as muscular dystrophy and obesity, suffered a fatal fall from the bed. The incident occurred when a CNA attempted to change the resident's brief alone, despite the care plan indicating the need for assistance from one or two staff members. The CNA moved the bed away from the wall and asked the resident to roll over, which led to the resident rolling off the bed and sustaining a serious head injury that resulted in death. Another resident experienced inadequate care related to catheter management and assistance with standing. The resident, who had multiple diagnoses including dementia and Parkinson's disease, was found to have his catheter leg bag positioned incorrectly while in bed, risking infection. Additionally, staff were observed pulling the resident by his right arm to assist him in standing, despite the resident's complaints of pain and visible bruising. This improper handling led to further injury, including a fractured clavicle and ribs, as confirmed by x-rays. Interviews with staff revealed a lack of specific training and awareness regarding the residents' care needs. The CNA involved in the fall with the first resident admitted to changing the resident alone due to shift change and being unaware of the proper procedures. Similarly, staff assisting the second resident were not informed of the extent of his injuries and continued to use inappropriate methods to help him stand, exacerbating his condition. These deficiencies highlight a significant gap in staff training and adherence to care plans, resulting in harm to the residents.
Removal Plan
- Resident #1 was discharged to the hospital.
- Resident #12 was reassessed by therapy to review level of assist for transfers. Staff working with Resident #2 were educated to follow the individual care plan that was updated on how to transfer safely with regards to his current fracture. Resident #2 was also reassessed regarding his catheter bag needs and the care plan was updated. Staff working with Resident #2 were educated to follow catheter needs as directed by care plan.
- An audit was completed by the DON and Infection Preventionist (IP) Nurse to ensure that all residents who require peri-care are care planned for level of assistance required with peri-care. All changes will be reflected in the Kardex for CNAs.
- An audit was completed by the DON and IP Nurse to ensure that all residents with current fractures are care planned for level of assistance required due to their injury. All changes will be reflected in the Kardex for CNAs.
- An audit was completed by the DON and IP Nurse to ensure that all residents with urinary catheter bags are care planned with catheter bag change instructions. All changes will be reflected in the Kardex for CNAs.
- Policies and procedures related to person centered care planning and resident rights were reviewed and utilized for education.
- Education of licensed nursing staff and CNAs related to providing peri-care per individual care planned needs will be completed. These staff will not be allowed to work until they have received the education which will be provided prior to the start of their shift.
- Education of licensed nursing staff and CNAs related to how to transfer a resident appropriately who have current fractures will be started. These staff will not be allowed to work until they have received their education and will receive education prior to the start of their shift.
- Education of licensed nursing staff and CNAs related to a resident's individualized catheter bag change needs will be completed to educate to follow the resident's care plans with regards to bag change needs.
- Medical Director was notified of the IJ.
- Root cause analysis completed and taken to QAPI.
- QAPI to be conducted.
Failure to Administer Diabetic Medications Leads to Hospitalization
Penalty
Summary
The facility failed to provide quality care for a resident with diabetes, leading to a serious health incident. Upon admission, the resident was not administered all prescribed diabetic medications, including Januvia, Glipizide, and Insulin glargine/Lantus, as per the hospital discharge summary. The facility only ordered Jardiance, and there was confusion regarding the resident's insulin requirement. This oversight was not clarified with the hospital, resulting in the resident not receiving necessary medications to manage her diabetes. The resident exhibited symptoms of high blood sugar, such as increased thirst, frequent urination, and fatigue, which were not adequately monitored or reported to a physician. Despite these symptoms, staff did not check the resident's blood glucose levels or administer the necessary medications. The resident's condition deteriorated over time, leading to an emergency room visit where she was diagnosed with diabetic ketoacidosis (DKA) and admitted to the hospital. Interviews with facility staff revealed a lack of communication and understanding of the resident's medical needs. The Assistant Unit Manager confirmed the confusion over the discharge paperwork and the failure to contact the hospital for clarification. Additionally, the Director of Nursing acknowledged that staff did not report the resident's symptoms or check her blood sugar levels, which they should have done according to the facility's diabetes policy.
Removal Plan
- Residents demonstrating signs and symptoms of hyperglycemia were transferred to the hospital.
- Residents with the diagnosis of diabetes mellitus will be audited to ensure orders are in place to reduce and/or prevent risk of severe adverse outcomes. Audits including blood sugar monitoring are included as part of the resident medication and/or treatment record.
- All applicable policies and procedures regarding admission assessment, physician orders and diabetic management were reviewed and revised when indicated by supporting professional references.
- The DON and Nursing Supervisors implemented a post admission checklist for all admissions. Admission Checklist is completed following completion of provider assessment and physician orders entry. Checklist includes review to ensure proper order transcription, correct medication administration, instruction for appropriate physician notification when residents demonstrate symptoms of hyperglycemia/hypoglycemia, review of necessary medical information and that the physician contact was properly documented. Checklist includes double checks by admitting nurse and unit manager.
- Admission checklist is completed following provider assessment at admission. Unit Manager/Nurse Supervisor will verify variances from documented treatment history to ensure orders are in agreement with treatment plan.
- The DON or designee re-educated licensed nurses on facility policies regarding admission procedures and diabetic management as well as medication reconciliation guidelines.
- Facility has secured additional providers to ensure that a provider is available in-house for all admissions. The provider will complete accurate review and completeness of admission assessments through reconciliation of all related admission documents.
- Medical providers have been trained on facility protocols regarding review of all related admission documents prior to or at admission. Providers shall document agreement with and/or changes with treatment history.
- Medical providers shall communicate with discharging entities to clarify any discrepancies in provided documentation.
- Direct care staff will be in-service regarding signs and symptoms of hypoglycemia and hyperglycemia and proper procedure to notify appropriate nursing staff.
- Direct care staff will be in-service on documenting all pertinent conversations in the electronic medical record.
- Licensed nursing staff will document communication with the provider through SBAR process. Evidence of notification will be included in the electronic health record.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to complete and document thorough investigations and implement corrective actions regarding allegations of neglect and abuse for three residents. Specifically, the staff did not investigate the allegations made by two residents who reported that a Certified Nurse Aide (CNA) was rude and made them feel bad for needing assistance. The allegations were not reported to the State Survey Agency (SSA), and there was no documentation of a thorough investigation. Additionally, another resident had injuries of unknown origin, and while an initial incident report was sent to the SSA, a required five-day follow-up report was not submitted. The facility's records showed that the staff involved continued to work without any investigation being conducted into the allegations. The lack of investigation and reporting led to the identification of Immediate Jeopardy by surveyors. The facility's failure to address these allegations appropriately resulted in a deficiency being cited. The staff did not follow the necessary procedures to ensure the safety and well-being of the residents, and the lack of documentation and investigation contributed to the severity of the deficiency.
Removal Plan
- A full abuse investigation will occur within the facility to ensure no other residents have witnessed abuse, or been abused.
- If any further abuse allegations are brought forward, the facility will remove any resident from the abuse situation, and proper monitoring and interventions will be initiated immediately upon notification.
- If any staff are identified in an allegation of abuse, they will be placed on administrative leave until the investigation is complete.
- The Interim Director of Nursing/designee re-educated current staff regarding abuse policy.
- The education includes the policy, with emphasis on separating the victim from the aggressor immediately and placing the aggressor on 1:1 supervision.
- Documentation needs to occur to reflect monitoring and clear discontinuation of the 1:1, and reasoning by a provider.
- If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed, and they have been cleared by the Administrator or DON to return.
- The provider, nurse manager, and family have to be notified immediately.
- The eInteract change in condition assessment needs to be completed filled out with all the details of what happened.
- Monitoring and interventions need to continue to happen and be documented if the resident remains in the building, until we know they have stabilized per the provider, or have left the center.
- The Interim Director of Nursing/designee will begin education and continue until all staff have been educated prior to their next shift.
- Any licensed staff member on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty.
- New hires/agency staff are educated on the abuse policy and process during orientation.
Failure to Prevent Falls and Inadequate Supervision
Penalty
Summary
The facility failed to prevent an accident for a resident who sustained 14 falls over a 6.5-month period. The resident, who had multiple diagnoses including dementia, anxiety, and repeated falls, was on a blood thinner medication, Eliquis, which increased the risk of bleeding. Despite being identified as high risk for falls, the facility did not implement adequate interventions to prevent these incidents. The care plan did not address the resident's use of Eliquis or the associated risks, and the facility failed to complete the required neurochecks following unwitnessed falls or falls involving head trauma. The resident's care plan included interventions such as reviewing past falls, considering urinary tract infections as a potential cause, and consulting urology, but these were not effectively implemented. The facility assigned one-to-one staffing for the resident, but staff were often given other duties, leading to inadequate supervision. This lack of supervision resulted in the resident experiencing multiple falls, some of which led to head injuries and required emergency room visits. The facility's failure to complete neurochecks as per policy further exacerbated the situation, as it hindered the monitoring of the resident's neurological status after falls. Interviews with the resident's daughter and staff revealed concerns about the facility's handling of the resident's care. The daughter expressed that the facility did not take sufficient action to mitigate the risk of falls, and the one-to-one staffing was not consistently provided. Staff interviews confirmed that they were assigned additional duties while supposed to be providing one-to-one care, which compromised the resident's safety. These deficiencies likely contributed to the resident sustaining multiple acute subarachnoid hemorrhages and passing away six days after the last fall.
Removal Plan
- Re-evaluation of all residents fall risks and care plans.
- Audit of previous falls to ensure new interventions were put in place and neurological checks were completed.
- Reeducation of staff regarding one-on-one staffing expectations and completing neurological checks.
Failure to Provide Adequate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by not providing adequate supervision after the resident expressed suicidal thoughts. The resident, who had a history of severe medical conditions including anoxic brain damage, acute respiratory failure, and depression, communicated her distress and desire to die to a Social Services Assistant (SSA). Despite this, the facility did not implement a one-on-one supervision or send the resident to the hospital as requested, which was a critical oversight given her mental state. The resident's care plan noted her communication difficulties due to a brain injury and tracheostomy, and she was known to express frustration with her condition. On the day of the incident, the resident told the SSA that she wanted to die and requested either one-on-one supervision or to be sent to the hospital. The SSA reported this to the nurse and the Director of Nursing (DON), but the facility only decided to conduct frequent checks instead of providing constant supervision. This lack of immediate and appropriate response led to the resident swallowing razor blades in a suicide attempt. Interviews with staff revealed that the resident was left unsupervised at the nurses' station, allowing her to return to her room and harm herself. The nurse on duty did not follow up on the resident's whereabouts after she left the nurses' station, and the DON was informed of the resident's suicidal ideation but did not ensure that a staff member remained with the resident as per the facility's Suicide Threats Policy. This series of inactions and miscommunications resulted in a serious incident that could have been prevented with proper adherence to the facility's policies.
Removal Plan
- The facility will identify any residents who have expressed a suicidal comment.
- Social Services will interview any residents identified to evaluate the mental condition of the resident in reference to any suicidal thoughts. The facility will immediately implement any measures per the facility's Suicide Threats Policy which are required to be initiated.
- Education of staff, which includes Administration, Direct Care Staff on the facility. Policy and procedures for suicide threats voiced by a resident.
- Staff will report any resident threats of suicide immediately to the Nurse Supervisor, Charge Nurse, DON/designee, and Physician.
- A staff member will remain with the resident until appropriate direction is provided by the physician.
- Any resident who expresses a suicide threat will be transferred to the hospital for evaluation.
- A psychiatric consultation will be initiated.
- Facility will initiate a facility wide sweep of all residents to determine if any residents exhibit suicide ideation. The facility will follow the following procedures: a. A standard format of questions will be utilized. b. The format will include the resident's name, person who is conducting the interview, and date of interview.
- Any residents identified at Risk for Suicide Ideation during facility-wide screening, Suicide Threat Policy will be initiated.
Deficiencies in Water Temperature Management and Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in the dementia care unit. Water temperatures were recorded to be excessively high, reaching up to 125 degrees Fahrenheit, which is above the safe limit of 120 degrees Fahrenheit. This issue affected six residents, all of whom had varying degrees of cognitive impairment, making them particularly vulnerable to the risk of burns. Despite initial adjustments to the water temperature, there was no consistent monitoring or documentation of water temperatures in resident rooms, leading to continued exposure to potential harm. Additionally, the facility failed to provide adequate supervision to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident experienced multiple falls, some resulting in injuries, without proper assessment or implementation of effective interventions to prevent future incidents. The resident's care plan included interventions such as a low bed and fall mats, but these measures were insufficient, as evidenced by the resident's repeated falls and injuries. The facility's documentation was lacking in assessments and investigations into the causes of the falls and injuries, and there was no evidence of additional interventions being put in place. The facility's inaction in both maintaining safe water temperatures and preventing falls placed residents at risk of serious injury. The lack of consistent monitoring and documentation, as well as the failure to implement effective interventions, highlights significant deficiencies in the facility's ability to provide a safe environment for its residents. These deficiencies were identified by surveyors, who noted the potential for serious harm due to the facility's failures.
Removal Plan
- Implementation of a removal plan through observations of water temperatures
- Review of education documentation
- Interviews with staff and the professional plumber
Improper Storage and Disposal of Narcotic Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of narcotic medications, which were found unsecured in the Director of Nursing's (DON) office. Observations revealed that the office was unlocked and accessible to residents, staff, and visitors, with various prescription bottles, including narcotics like morphine and fentanyl, left on the desk and in an open box on the floor. These medications were undated and not labeled with the residents' names, violating the facility's policy that requires controlled substances to be stored under double lock and accessible only to licensed nursing staff. Interviews with staff members, including the DON, revealed a lack of adherence to the facility's medication management policies. The DON admitted to not logging narcotics due to being busy and confirmed that medications should not be left unsecured in her office. Other staff members reported observing narcotics in the DON's unlocked desk drawers and expressed concerns to the administration and corporate human resources, but no action was taken. Additionally, the facility's process for disposing of unused and expired medications was inadequate, with the DON stating that medications were held for months before destruction, contrary to the policy requiring immediate logging and secure storage. Further investigation uncovered that the Infection Control Storage room contained unlabeled boxes and bins of medications, some dating back to 2022, without any destruction logs. The facility's medication reconciliation logs lacked documentation for these medications, and the Administrator was unaware of their presence. Interviews with other staff members corroborated the DON's failure to follow proper procedures, with reports of narcotics being hidden during inspections and a lack of organization in medication storage rooms. These deficiencies led to the identification of Immediate Jeopardy, highlighting significant risks to resident safety due to improper medication management.
Removal Plan
- A full audit of current medications for destruction was performed to ensure all medication was accounted for, logged, secured, and locked in a medication storage area or lock box until pick-up was completed or pharmacy destruction was initiated.
- All nursing staff was re-educated on Medication Storage Policy.
- The Director of Nursing/designee began education. 100% of currently scheduled staff have been educated on this information (Medication Storage). Any staff member that is not on the current schedule will be educated prior to returning to their next shift.
- New hires/agency staff will be educated during orientation.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when nursing staff administered the wrong dose of medication. A resident, who was initially admitted and later discharged, experienced an altered mental status, tachycardia, low blood pressure, and hypoxia. The resident was found in a distressed state by a CNA and was taken to the nursing station for vital sign assessment. The resident's condition required immediate medical intervention, including the administration of morphine as ordered by a nurse practitioner. The error occurred when an LPN, in an emergency situation, borrowed morphine from another resident's supply and administered it to the affected resident. The LPN was unsure of the correct dosage and administered 40 milligrams instead of the prescribed 2 milligrams. This mistake was compounded by the fact that the LPN did not use the specific syringe designed for the morphine prescription, leading to the overdose. The resident became less responsive after receiving the incorrect dose, prompting staff to call EMS for hospital transfer. The facility's records did not document the administration of morphine to the resident, and there was no evidence that the hospital ER was notified of the medication error. The resident was admitted to the hospital with several health issues, including sepsis, pneumonia, and acute renal failure, and later passed away. The facility's failure to properly administer medication and document the incident resulted in significant harm to the resident.
Removal Plan
- An audit will be completed of every resident with a narcotic order, to ensure that all narcotics ordered are on the medication carts. If medications are missing, then the medication availability process will be followed and pulled from the Omnicell/Ekit.
- All nursing staff will be re-educated on the six rights of medication administration with an emphasis on right patient/resident and right dosage.
- Nurse manager/designee will provide education to all nursing staff on medication availability process.
- A unit manager will begin education and continue until all licensed nursing staff have been educated prior to their next shift. New hires/agency staff will be educated during orientation.
- A unit manager will begin education. 100% of currently scheduled staff will be educated on this information. Any staff member that is not on the current schedule will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.
- The Director of Nursing/designee will begin education. 100% of currently scheduled staff will have been educated on this information. Any staff member that is not on the current schedule will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.
Deficiencies in Nursing Staff Competency and Hiring Practices
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competency and skills, leading to several deficiencies. An LPN, who also served as a Unit Manager, failed to administer accurate medication dosages to a resident, resulting in the resident being admitted to the hospital for difficulty breathing and altered mental status. Additionally, the LPN did not follow the facility's process for receiving emergency medications and inaccurately documented on the medication administration record to intentionally deceive. The facility's policies required staff to utilize the Automated Medication Dispensing Systems and report medication errors, but these protocols were not followed. Furthermore, another LPN began working without completing an application, having a background clearance, or demonstrating competency prior to providing care to residents. This LPN worked for three shifts without the necessary background checks, TB testing, or training. The Payroll/Scheduler discovered that this LPN was not a hired employee and had used another LPN's credentials to log into the electronic medication record system. The Administrator and Corporate Human Resources were notified but initially instructed to expedite the hiring process instead of addressing the unauthorized work. The facility's hiring policy required offers of employment to be contingent upon successful completion of hiring requirements, including background checks and health screenings. However, these procedures were not followed, as evidenced by the lack of documentation for the LPN's background clearance and training prior to working. The Administrator was unaware of the unauthorized work until informed by the Payroll/Scheduler, highlighting a breakdown in communication and oversight within the facility's management.
Removal Plan
- A full audit of all current staff working in the center will occur to ensure the proper hiring process was completed, including screening and training, with emphasis on: background checks, finger prints, Electronic Health Record (EHR) access.
- Anyone identified as not meeting these requirements will be removed from the schedule until requirements are met.
- A full audit of current direct care staff will occur to ensure all direct care staff have their own EHR access.
- Market Human Resources/designee will re-educate current management staff on hiring process, including required screening and training prior to beginning work within the center.
- Nurse manager/designee will provide education to all staff that they are never to use another staff member's sign-in for any application. If they are unable to use their own sign-in, they will contact IT and/or management until their access issues have been resolved.
- Education will continue until all identified staff have been educated prior to their next shift. Any management staff member on leave of any type, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire.
- The Administrator/designee will review new hires daily to ensure the process for new hires is being followed.
- The Director of Nursing/designee will begin education. 100% of currently scheduled staff will have been educated on this information. Any staff member that is not on the current schedule, is on leave of any type, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.
Medication Administration Error Due to LPN's Incompetency
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in safely administering medications, which led to a significant medication error. An LPN pre-poured medications and, due to distraction, handed them to the wrong resident. This error resulted in the resident receiving another resident's medications, including Prilosec and lisinopril, which caused hypotension and required hospitalization for observation and treatment. The LPN did not immediately report the error to the physician or the Director of Nursing (DON), further compounding the issue. The resident who received the wrong medications experienced a significant drop in blood pressure and was found dizzy and on the floor by a housekeeper. The resident was subsequently sent to the emergency room, where he was evaluated and admitted for observation. The hospital records indicated that the resident was hypotensive due to the medication error but remained stable without any overnight events and was discharged back to the nursing home the following day. The facility's investigation revealed that the LPN had previously been written up for pre-pouring medications and had completed initial and re-education competency assessments. Despite this, the LPN failed to follow the five rights of medication administration, leading to the error. Observations of other nursing staff showed that they followed proper procedures for medication administration, including verifying resident identity and medication details. The DON confirmed that new staff shadow senior nurses and complete competency assessments annually, but this incident highlighted a lapse in adherence to these protocols.
Removal Plan
- LPN #1 was immediately suspended pending investigation for delayed notification of medication error.
- All residents on LPN #1's assignment were evaluated for changes in status and screened for concerns related to their medication to rule out the potential of other medication errors. All resident audits were completed by nursing staff. The residents did not have changes from their baseline.
- All nurses and CMAs to be educated on the five rights of medication administration related to resident identification. In-service and ongoing.
- Random medication administration observations to be completed by DON or Designee three times per shift. Evaluate and bring results to Quality Assurance Performance Improvement (QAPI) monthly until determination of stop. Start date and ongoing.
- LPN #1 was terminated from the facility and turned into the New Mexico Board of Nursing.
Failure to Monitor Bowel Movements Leads to Resident's Death
Penalty
Summary
The facility failed to adequately monitor and address the bowel movements of a resident, leading to severe medical complications. The resident, who had multiple diagnoses including severe protein-calorie malnutrition and muscle weakness, was not properly monitored for constipation despite being at risk for gastrointestinal symptoms. The care plan directed staff to assess and report signs of constipation, but the CNAs did not document any bowel movements for extended periods, and there was no record of a laxative being administered as per the facility's physician orders. The resident experienced significant abdominal pain and was eventually transferred to the hospital, where a rectal exam revealed a large fecal burden and evidence of chronic constipation and fecal impaction. The resident's condition deteriorated, resulting in gastrointestinal hemorrhaging and ultimately, death due to acute myocardial infarction. Interviews with staff revealed communication barriers and a lack of consistent monitoring, contributing to the oversight in the resident's care. The facility's Director of Nursing confirmed that CNAs should have been monitoring and reporting bowel movements daily, but this was not done for the resident. The failure to follow established protocols for bowel management and the lack of communication among staff members were significant factors in the deficiency, leading to the resident's severe health decline and eventual death.
Removal Plan
- Licensed nurses will complete assessments on current residents residing in center to determine if any residents were constipated or without bowel movement for greater than three days.
- For those who could not answer and had no current documentation, an abdominal assessment will be completed.
- Any resident that is independent with toileting will be identified and care plan/kardex will be updated to indicate needed monitoring.
- CNAs will document their findings in POC which will be monitored daily by the nurse manager.
- Identified issues will be reported to the provider for further direction; medical orders and change in condition process will be implemented.
- If a resident is identified as needing immediate medical assistance, 911 will be called and the patient will be transferred to an ER for evaluation.
- The Director of Nursing re-educated current licensed staff regarding policy for resident change in condition.
- Documentation of ADLs by end of shift, including bowel movements.
- CNAs should be alerting nurses if a resident has not had a bowel movement within the past three days, and with consistency concerns like very hard, compacted bowel movement, and loose.
- The nurse should use medications/interventions per reference orders provided by the Medical Director for bowel management. If this intervention does not work, the CIC process needs to be followed and provider/family needs to be notified.
- Then a bowel management plan needs to be implemented.
- The Director of Nursing/designee will begin education.
- Any staff member that is not on the current schedule, is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires and agency staff will be educated during orientation.
- Agency staff are currently and will continue to be educated by the facility human resources and mentor as part of the orientation process, prior to their first shift.
- Nurse management/designee will monitor CNA documentation on all shifts via dashboard to ensure documentation is being completed timely.
- Nurse management will review the dashboard daily in clinical meeting for bowel alerts and follow-up will occur with nurses and CNAs to ensure processes are followed.
- The Director of Nursing/designee will review resident progress notes, orders, and nursing dashboard during morning clinical meeting to determine if residents noted change in condition identified, and process followed, including monitoring and interpretive services are being used.
- The Director of Nursing/designee will audit CNA documentation daily in clinical meetings five days per week for one month, then weekly times two months.
- Five random independent residents will be interviewed weekly to ensure that bowel movements are accurately documented for independent residents, times one month. Then three random residents for two months.
- Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next three months or until ongoing compliance is achieved.
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