Citations in New Mexico
Statistics, citations 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 CVA and dementia, and severe cognitive impairment, received trazodone for depression without a completed medication consent form before the medication was administered. The record also showed a pharmacist-recommended GDR was declined with documentation that family routinely declines GDRs, but the rationale did not state that a further dose reduction would likely impair function or cause psychiatric instability, as required.
A resident with CVA, dementia, and neurogenic bladder had a physician order for the urinary catheter drainage bag to be kept below the knee for proper gravity drainage. Staff observed and confirmed the bag was instead secured above the knee on the resident’s thigh each shift because the spouse wanted it positioned that way, despite the order and care plan directing otherwise.
Failure to report a resident fall with injury: A resident with dementia, generalized weakness, and repeated falls fell due to an unsteady gait, struck his head, sustained a head laceration, and was transferred to the hospital, where a scalp hematoma was diagnosed. The facility did not submit the required incident summary report and follow-up investigation results to the State Agency, and the DON and ADM stated the event should have been reported.
A resident with dementia, generalized weakness, and repeated falls was found on the bathroom floor after an unwitnessed fall, and nursing notes stated neuro checks were started per protocol. However, the EHR did not contain the required neuro assessments or follow-up documentation, and the DON said the paper forms were not in the chart, so it could not be determined whether the assessments were completed.
A resident with severe dementia, weakness, and mobility impairment was left outside in direct sunlight for an unknown period after staff failed to maintain supervision. An activity assistant saw the resident in the courtyard, assumed someone else would return for him, and later found him slumped over and twitching; a CNA delayed responding, and the resident was ultimately found unresponsive. EMS and hospital records documented AMS, hyperthermia, dehydration, hypotension, low SpO2, rapid respirations, and sunburns with blistering and peeling skin.
An LPN verbally abused a resident by making degrading comments about meth use, teeth loss, and living in the facility, and another resident reported hearing the abuse and later being confronted after filing a grievance. The abused resident, who had intact cognition and diagnoses including anxiety, bipolar disorder, seizure disorder, and DM2, reported fear, embarrassment, sleep disturbance, and distrust of the LPN. The facility’s investigation substantiated an inappropriate remark but the LPN was not suspended and continued working regular shifts.
Psychotropic Medication Consent and GDR Documentation Failure
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medication use when trazodone was administered without a completed medication consent form before the medication was given. The resident had been admitted with diagnoses of CVA and dementia, and the MDS showed severe cognitive impairment with a BIMS score of 02. The record showed trazodone 50 mg was ordered for depression beginning on 09/20/24, but the medication consent form was not obtained until 03/03/25, after the medication had already been in use. The record also showed that a pharmacist recommended a gradual dose reduction for trazodone on 04/23/26, but the provider declined and documented the reason as "Family routinely declines GDRs." The report stated this rationale did not document that an additional dose reduction would likely impair the resident's function or increase distressed behavior, as required. A later pharmacist recommendation for a GDR on 06/30/26 was accepted. Interviews with the POA, RN, LPN, pharmacist, and DON confirmed that medication consent was required before administering psychotropic medication and that the documented reason for not attempting the GDR did not meet the required standard.
Urinary Catheter Drainage Bag Positioned Contrary to Physician Order
Penalty
Summary
The facility failed to meet professional standards of quality for one resident when staff did not follow the physician order for placement of the urinary catheter drainage bag. The resident was admitted with CVA, dementia, and neurogenic bladder, and the BIMS score was 02, indicating severe cognitive impairment. The physician order dated 03/10/25 directed staff to check the urinary catheter tubing and drainage bag placement every shift to ensure the bag remained below the knee for proper gravity drainage. The resident’s care plan dated 12/22/25 identified that the resident used a urinary catheter and directed staff to educate the resident and family regarding catheter care. During observation, the drainage bag was secured to the resident’s right thigh and positioned above the knee while the resident sat in a wheelchair. Staff interviews confirmed the bag was kept above the knee and on the thigh each shift, and the RN, LPN, and DON stated this was done because the resident’s spouse wanted it positioned that way, despite the physician order stating it should be below the knee.
Failure to Report Resident Fall With Injury
Penalty
Summary
The facility failed to submit the required incident summary report and five-day follow-up investigation results to the State Agency for one resident who experienced a fall with injury. The resident had diagnoses including non-Alzheimer's dementia, generalized muscle weakness, and repeated falls. Nursing progress notes documented that the resident fell due to an unsteady gait, struck his head, sustained a head laceration, and was transferred to the hospital for evaluation. The hospital discharge summary documented a scalp hematoma after the fall. The facility's accidents and incidents policy stated that staff are expected to report, review, and investigate all resident accidents and incidents, and that the Administrator and/or DON will verify state reporting occurred within required timeframes. During interviews, the DON stated the fall should have been reported because the resident sustained a head laceration and required hospital transfer, and the Administrator stated the event should have been reported because the resident was transferred to the hospital following the fall. The Administrator also stated there was no documentation showing the fall had been reported to the State Agency.
Incomplete Documentation After Unwitnessed Fall
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident after an unwitnessed fall. The resident had diagnoses including non-Alzheimer's dementia, generalized muscle weakness, and repeated falls. After the resident was found lying on the bathroom floor following the unwitnessed fall, nursing progress notes stated that neurological checks were started per facility protocol. Record review showed the resident's electronic health record did not contain the neurological assessments or follow-up documentation from after the fall. The DON stated the facility's protocol required neurological assessments every 15 minutes for the first hour, then every 30 minutes for a total of four assessments, followed by hourly assessments for a total of four assessments, and that these were documented on a paper form expected to be uploaded into the EHR. The DON stated the forms for this resident were not present in the EHR and that she could not determine whether the assessments had been completed because they were not documented.
Resident Left Outside in Sunlight and Found Unresponsive
Penalty
Summary
The facility failed to ensure a resident was free from abuse and neglect when staff left the resident outside in direct sunlight for an unknown period of time. The resident had a diagnosis of severe dementia with psychotic disturbance, muscle weakness, lack of coordination, gait and mobility abnormalities, and required substantial to maximal assistance with transfers and partial to moderate assistance with wheelchair propulsion. The care plan directed staff to cue, reorient, and supervise the resident as needed, and to anticipate and meet his needs because of communication problems. On the day of the event, the resident was first seen in the courtyard by an activity assistant at about 1:30 pm. The resident declined help back inside, and the activity assistant assumed whoever took him outside would return for him. Later, another resident reported that he was outside and leaning over in his wheelchair. The activity assistant notified a CNA assigned to the resident’s hall, but the CNA said she would get him after finishing making a bed. A few moments later, the activity assistant saw the resident twitching and then notified another CNA, who went outside with her and directed her to get a nurse. When staff reached the resident, he was slumped over in his wheelchair and unresponsive. EMS was called and found the resident outside and unresponsive after an unknown amount of time. The facility staff could not say when they last saw him, although one nurse later stated she remembered seeing him at lunch. The resident was brought inside, placed in bed, and cooled with wet washcloths and cold packs. EMS and hospital records documented altered mental status, hyperthermia, dehydration, low blood pressure, low oxygen saturation, rapid respirations, and sunburns on both legs, both arms, and the top of the head. A later observation showed blisters and peeling skin on the thighs, ruptured blisters on both forearms, and blisters on the top of the head.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when an LPN verbally abused a resident by making derogatory comments about methamphetamine use, teeth loss, and living in the nursing home. The resident who was targeted had diagnoses including anxiety disorder, bipolar disorder, seizure disorder, and type 2 diabetes mellitus, and had a BIMS score of 15, indicating intact cognition. The resident reported feeling embarrassed, unsafe, fearful of retaliation, and unable to trust the LPN with medications, and stated the comments caused sleep disturbance and nightmares. A second resident, who also had a BIMS score of 15 and diagnoses including seizure disorder, anxiety disorder, and depression, reported hearing the LPN speak badly to the other resident and stated the LPN was rude and condescending to him and other residents. This resident filed a grievance after hearing the verbal abuse and later stated the LPN confronted him afterward by saying, "Thanks for writing a grievance on me." The resident stated he did not feel the comments affected him personally, but he was upset by the way he was spoken to. The facility’s investigation found that the LPN made an inappropriate remark referencing methamphetamine use during a verbal exchange with the resident, but the investigation did not support all of the allegations. The report states the accused staff member was not suspended during the investigation and continued to work regular shifts. The administrator stated the allegations were not reported and that the LPN was removed from the resident’s care but not suspended because she did not believe the conduct met the criteria for abuse. The report also states the LPN had only one documented abuse and exploitation inservice and that there were no records of corrective actions completed for the LPN.
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Compliance trends in New Mexico
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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