1. A. A resident assessment shall be completed by an appropriate staff member within 15 days prior to admission to determine the level of assistance that is needed and if the level of services required by the resident can be met by the facility.
2. B. The initial resident assessment shall establish a baseline in the resident’s functional status and thereafter assist with identifying resident changes. The resident assessment shall be reviewed and updated at a minimum of every six months or when there is a significant change in the resident’s health status.

3. C. The residents’ assessment shall be documented on a resident evaluation form and at a minimum include the following abilities, behaviors or status:

   1. (1) activities of daily living including:

      1. (a) toileting pattern, bowel, and bladder control;
      2. (b) dressing, grooming, bathing, and personal hygiene;
      3. (c) mobility, including ambulation, transfers, and assistive devices; and
      4. (d) eating, dental status, oral care, and assistive devices and dentures, if applicable.
   2. (2) cognitive abilities; reasoning and perception; the ability to articulate thoughts, memory function or impairment, etc.;
   3. (3) communication and hearing; ability to communicate needs and understand instructions, etc.;
   4. (4) vision;
   5. (5) physical functioning and skeletal problems;
   6. (6) incontinence of bowel/bladder;
   7. (7) psychosocial well-being;
   8. (8) mood and behavior;
   9. (9) activity interests;
   10. (10) diagnoses;
   11. (11) health conditions;
   12. (12) nutritional status;
   13. (13) oral or dental status;
   14. (14) skin conditions;

   15. (15) medication use including prescriptions, over-the-counter medications, and supplements, and for each:

       1. (a) the reason taken;
       2. (b) any side effects, contraindications, allergic or adverse reactions, and actions to address these issues;
       3. (c) the dosage;
       4. (d) the frequency of use;
       5. (e) the route administered or taken;
       6. (f) any difficulties the resident faces in taking the medication;
       7. (g) whether the resident self administers the medication;
       8. (h) the resident's preferences in how to take medication;
       9. (i) interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications; and
       10. (j) provide instructions to the resident and resident's legal or designated representatives on interventions to manage the resident's medications and prevent diversion of medications.
   16. (16) special treatments and procedures or special medical needs such as hospice; and
   17. (17) safety needs/high risk behaviors; history of falls agitation, wandering, fire safety issues, etc.

   18. (18) instrumental activities of daily living, including:

       1. (a) ability to self manage medications;
       2. (b) housework and laundry; and
       3. (c) transportation.

   19. (19) risk indicators, including:

       1. (a) risk for falls including history of falls;
       2. (b) emergency evacuation ability;
       3. (c) complex medication regimen;
       4. (d) risk for dehydration, including history of urinary tract infections and current fluid intake pattern;
       5. (e) risk for emotional or psychological distress due to personal losses;
       6. (f) unsuccessful prior placements;
       7. (g) elopement risk including history or previous elopements;
       8. (h) smoking, including the ability to smoke without causing burns or injury to the resident or others or damage to property; and
       9. (i) alcohol and drug use, including the resident's alcohol use or drug use not prescribed by a physician.
4. D. The resident medical evaluation shall include a history and physical examination and an evaluation report by a physician or a physician extender within six months of admission. A resident shall have a medical evaluation by a physician or a physician extender at least annually. The facility shall document the resident’s refusal to undergo or share the results of an annual medical visit with a physician or physician extender.
5. E. The resident assessment shall be reviewed and if needed revised by a licensed practical nurse, registered nurse or physician extender at the time the individual service plan is reviewed, at a minimum of every six months or when a significant change in health status occurs.

[8.370.14.25 NMAC - Rp, 8.370.14.25 NMAC, 12/23/2025]