Deficiency Records for Mimbres Memorial Nursing Home

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Updated as of March 01, 2024

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?
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2024-01-16 2024-03-01 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2024-01-16 2024-03-01 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 2024-03-01 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 2024-03-01 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 2024-03-01 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-16 2024-03-01 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 2024-03-01 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 2024-03-01 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 2024-03-01 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-01-16 2024-03-01 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 2024-03-01 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 2024-03-01 N
Provide or obtain dental services for each resident. Health 2024-01-16 2024-03-01 N
Provide and implement an infection prevention and control program. Health 2024-01-16 2024-03-01 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2024-01-16 2024-03-01 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-01-16 2024-03-01 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 2024-03-01 N
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2024-01-16 2024-03-01 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
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 2024-02-26 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-01-16 2024-02-26 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-01-16 2024-02-23 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2024-01-16 2024-02-12 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2024-01-16 2024-02-12 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