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Deficiency Records for Mimbres Memorial Nursing Home
A list of the most recent deficiencies for Mimbres Memorial Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mimbres Memorial Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-23 | 2024-09-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-23 | 2024-09-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-23 | 2024-09-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-23 | 2024-08-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-07 | 2024-04-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-07 | 2024-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-07 | 2024-04-15 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-03-07 | 2024-04-15 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-01-16 | 2024-04-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-16 | 2024-04-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-16 | 2024-04-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-01-16 | 2024-04-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-16 | 2024-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-16 | 2024-04-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-16 | 2024-04-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-16 | 2024-04-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-16 | 2024-04-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-16 | 2024-04-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-16 | 2024-04-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-16 | 2024-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-16 | 2024-04-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-01-16 | 2024-04-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-16 | 2024-04-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-01-16 | 2024-04-15 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-01-16 | 2024-04-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-01-10 | 2024-03-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-10 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-03-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-01-10 | 2024-03-01 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-08-08 | 2023-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-08 | 2023-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-08 | 2023-09-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-07 | 2023-01-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-07 | 2023-01-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-07 | 2023-01-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-07 | 2023-01-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-11-29 | 2023-01-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-29 | 2023-01-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-29 | 2022-12-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-11-29 | 2022-12-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-11-18 | 2022-01-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-18 | 2022-01-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-18 | 2022-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-18 | 2022-01-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-18 | 2022-01-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-18 | 2022-01-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-18 | 2022-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2022-01-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-18 | 2022-01-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-23 | 2021-12-31 | N |
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