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 DM2, acute cystitis, HTN, and severe burns had hypotension and a change in condition, with a BP of 88/51 and later a doctor’s visit that led to ER transfer for low BP. The DON, RN, and NP stated the NP was notified of the low BP and instructed staff to give oral fluids and recheck the BP, but staff did not document the repeat BP or call the NP back with the updated result, and one hypotension episode was not documented as reported.
IV Antibiotic Not Administered as Ordered: A resident admitted with sepsis and endocarditis had an order for IV Ampicillin q4h, but the IV tubing remained clamped and the dose was given 2 hours and 30 minutes late. RN, the UM, and the DON all confirmed the resident did not receive the IV antibiotic as ordered because the clamp was not opened.
A resident with DM2, malnutrition, and no teeth did not receive the ordered controlled carbohydrate diabetic diet. The hospital discharge orders, facility admission summary, and NP notes all indicated a diabetic diet, and the niece requested an easy chew diabetic diet due to chewing difficulty. The RD, DON, and NP stated the resident should have received the ordered therapeutic diet.
Failure to Accurately Assess and Track a Worsening Pressure Ulcer: A resident with MS, dementia, malnutrition, incontinence, and poor mobility had a sacral/coccyx wound that was repeatedly documented with inconsistent descriptions such as abrasion, excoriation, small opening, and pressure ulcer. The wound was not consistently measured, staged, or tracked, and the DON stated the facility did not identify or document the wound’s characteristics before it was later diagnosed as an infected Stage 4 pressure ulcer with exposed bone, purulent drainage, cellulitis, and osteomyelitis.
The facility failed to maintain infection control for multiple residents. A resident with a worsening sacral wound and antibiotic orders was not tracked in the antibiotic stewardship or infection control programs and did not have EBP signage posted. Two other residents with sepsis, a stage 4 PU, ESBL, and E. coli also lacked EBP signs, and staff observed providing high-contact care without PPE.
A resident with MS, dementia, and CKD began hospice care, but the facility did not complete a significant change MDS to reflect the hospice status. The DON confirmed the resident was admitted to hospice and that no significant change MDS was completed.
Failure to Notify Provider and Document Follow-Up Blood Pressure After Hypotension
Penalty
Summary
The facility failed to notify the provider and document follow-up after a resident experienced hypotension and a change in condition. The resident had diagnoses including DM2, acute cystitis, HTN, and third degree burns. On 05/13/2026, the resident’s blood pressure was 88/51, and the provider recommended oral fluids, a repeat blood pressure check, and reporting the results back to the provider. The record also showed that the resident later attended a doctor’s appointment and was sent to the ER due to hypotension, with a diastolic blood pressure reportedly in the 50s upon arrival. During interviews, the DON stated the resident had episodes of hypotension on 05/11/2026 and 05/13/2026, and that the NP was notified on 05/13/2026, but the notification for the 05/11/2026 episode was not documented. RN #1 stated she notified the NP about the low blood pressure and was instructed to encourage oral fluids and recheck the blood pressure, but she failed to follow up with the NP and document the repeat blood pressure after fluids were given. The NP stated she was not called back with an updated blood pressure reading and assumed the resident improved with oral hydration, but later learned the resident was sent to the hospital for evaluation due to hypotension.
IV Antibiotic Not Administered as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident who was admitted with sepsis and endocarditis. The resident had a physician order for Ampicillin Sodium 2 grams to be given intravenously every four hours until 05/31/2026. Facility documentation showed that the IV antibiotic was not administered at the scheduled time because the IV tubing remained clamped, and the resident received the medication 2 hours and 30 minutes late. The physician was notified of the medication error. During interviews, RN #1 stated the resident was scheduled to receive IV Ampicillin at 6:00 AM, but the night nurse who connected the IV antibiotic did not open the IV clamp as expected, so the resident did not receive the medication as ordered. The Unit Manager stated the night nurse did not release the IV clamp and the resident did not receive the scheduled IV antibiotics as prescribed. The DON stated it was her expectation that residents receive antibiotics and medications as ordered by a physician, and that if a resident does not receive the antibiotic regimen as ordered, it could extend or alter the course of treatment.
Failure to Implement Ordered Diabetic Diet
Penalty
Summary
The facility failed to implement a physician-ordered therapeutic diet for one resident with Type II diabetes, malnutrition, and a pressure ulcer. Record review showed the resident was re-admitted on 04/30/2026 and had hospital discharge orders for a diabetic diet, with the facility admission summary also indicating a diabetic diet was to be provided. The resident’s NP progress notes on 05/02/2026, 05/07/2026, and 05/11/2026 documented a controlled carbohydrate diet. Interviews and record review showed the resident’s diet did not match the ordered therapeutic diet. The resident’s niece stated the resident had diabetes and difficulty chewing because the resident had no teeth, and she requested an easy chew diabetic diet during a care conference. The RD stated residents with diabetes should receive a consistent carbohydrate diabetic diet and residents without teeth should receive an altered texture diet appropriate for chewing difficulties, and that the resident should have been receiving a controlled carbohydrate diabetic diet as ordered. The DON and NP #1 both stated residents with diabetes or hospital orders for a diabetic diet should receive the ordered therapeutic diet, and NP #1 noted that if the diabetic diet order was not entered into the EHR, the resident could receive a regular diet.
Failure to Accurately Assess and Track Worsening Pressure Ulcer
Penalty
Summary
The facility failed to accurately identify, assess, measure, stage, monitor, document, report, and adjust care for a resident’s coccyx/sacral pressure ulcer. The resident had multiple sclerosis, dementia, protein-calorie malnutrition, bowel incontinence, poor mobility, and a history of a sacral pressure ulcer on admission. The care plan identified the resident as at risk for skin impairment and included interventions such as pressure-relieving devices, frequent repositioning, keeping skin clean and dry, and weekly skin checks, but the wound documentation did not consistently reflect the wound’s location, characteristics, or progression. Record review showed the resident’s sacral/coccyx skin issue was repeatedly described in inconsistent terms, including abrasion, excoriation, small opening, and pressure ulcer, with several entries stating that the wound was stable, improved, or resolved. One skin check noted a pressure ulcer on the coccyx with no measurements documented and a note that the wound nurse would measure it. Later documentation described the wound as an excoriation with a small opening, then as a wound measuring 3.5 cm by 5.5 cm with 50% epithelial tissue and light clear drainage. The facility’s records did not show consistent staging or accurate tracking of the wound’s worsening condition before it was later identified as a Stage 4 pressure ulcer with exposed bone, purulent drainage, cellulitis, and concern for osteomyelitis. The resident’s hospice and wound clinic records documented a large, non-healing sacral wound with purulent drainage, odor, necrotic tissue, and progressive deterioration. The wound clinic measured the wound as a Stage 4 pressure ulcer with exposed bone and cellulitic surrounding tissue and sent the resident to the emergency department. The emergency department documented a Stage 4 decubitus ulcer with purulent drainage, foul odor, exposed bone, erythema, tachycardia, hypotension, high white blood cell count, and osteomyelitis. During survey interviews, the DON stated the facility did not identify or document any characteristics of the wound prior to the hospital physician diagnosing it as an infected Stage 4 pressure ulcer, and there was no documented evidence that staff notified the physician of the wound’s progression.
Infection Control and Enhanced Barrier Precautions Not Followed
Penalty
Summary
The facility failed to maintain an effective, comprehensive infection prevention and control program for three residents. For one resident with a sacral wound that progressed from excoriation to a stage 4 pressure injury, the record showed orders for Bactrim and later Doxycycline, but the resident was not included in the antibiotic stewardship monitoring program and was not tracked in the facility’s infection control program for February, March, and April 2026. The facility also did not have enhanced barrier precautions in place for this resident during those months, and a CNA confirmed there was no EBP sign posted on the resident’s door. For another resident admitted with sepsis, a stage 4 sacral pressure ulcer, and need for assistance with personal care, an OT observed providing high-contact care and confirmed she was not wearing PPE, and there was no EBP sign posted. For a third resident admitted with ESBL resistance and unspecified E. coli, the physician ordered enhanced barrier precautions with a sign on the door and gown and gloves for all high-contact care, but a CNA confirmed there was no EBP sign posted and that she performed high-contact care during a brief change without PPE.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change MDS within 14 days after a resident began hospice care. Record review showed the resident was admitted with diagnoses of MS, dementia, and CKD. The Hospice Election Form was dated 03/26/26 and showed hospice care began on 03/27/26, but the most recent MDS assessment indicated the resident was not on hospice. During an interview on 05/14/26 at 4:10 pm, the DON stated that the resident was admitted to hospice on 03/27/26 and did not have a significant change MDS to reflect hospice care.
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Compliance trends in New Mexico
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 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): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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 Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in New Mexico
- Provided change-in-condition (CIC) education to LPN and RN staff covering definition of CIC, appropriate provider communication, nursing follow-up and documentation responsibilities, consequences of delayed intervention, and importance of timely notification/early recognition and intervention (K - F0580 - NM)
- Ensured all nurses on duty since the event received CIC education with DON/designee verification to reinforce staff responsibility for timely CIC recognition and notification (K - F0580 - NM)
- Reviewed and clarified the non-emergent provider communication log process with the provider and administration team to define appropriate acuity of notifications (K - F0580 - NM)
- Required that changes of condition be reported directly to the provider and restricted the non-emergent log to non-emergent requests/medication refills to prevent delayed escalation (K - F0580 - NM)
- Updated the non-emergent provider communication log form to reflect the revised escalation/notification process (K - F0580 - NM)
Failure to Notify POA and Providers of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify resident representatives and providers of significant changes in condition for two residents. For one resident with traumatic hemorrhage of the right cerebrum, carotid artery aneurysm, convulsions, and a cognitive communication deficit, the face sheet and POA documents identified the spouse as POA and first emergency contact, and the son as second emergency contact and secondary POA. Social services documentation and nursing notes showed that this resident explicitly stated that her husband should be the first person notified of any changes in condition and her son the second. Despite this, multiple SBAR forms documented repeated changes in condition, including abnormal vital signs with unresponsiveness, new swallowing issues, a positive COVID test, swallowing difficulties, a fall with head injury, an altercation with another resident, a seizure, and another fall. In each of these events, staff notified only the resident’s daughter‑in‑law, identified as the resident representative, and did not notify the husband or son as emergency contacts/POA. Interviews further confirmed the pattern of non‑notification of the appropriate decision‑makers for this resident. The son reported that the facility did not notify him after any of the resident’s changes in condition and that he learned of these events from the resident representative instead. The husband/POA stated he did not recall being notified by the facility regarding any of the changes in condition and did not know who the facility contacted. The resident representative stated that staff began contacting her instead of the husband and son, sometimes because they did not answer the phone, and acknowledged that this practice bothered the son. The Unit Manager stated that facility nursing staff were required to call the POA and emergency contact for any change in condition and that if a family member onsite was not the POA, staff should still notify the POA. She acknowledged that nursing staff should have contacted the resident’s husband or son regarding the changes in condition, even when the resident representative was present in the facility. For the second resident, who had dementia with behavioral disturbance, chronic respiratory failure with hypoxia, chronic CHF, and hypoglycemia, and who was documented as full code with all interventions, the facility failed to notify a provider when the resident exhibited an acute change in condition. Nursing progress notes documented that in the early morning hours, the resident was mouth breathing with gurgling sounds in the deep throat, had non‑productive coughing, an oxygen saturation of 92% on 3 liters of oxygen, and was uneasily aroused by tactile/verbal stimuli, with abnormal lung sounds including bilateral upper lobe rhonchi and diminished lower lobe sounds. The nurse recorded that the primary care physician was made aware via a non‑emergent in‑house communication log for further evaluation and treatment, and that the oncoming nurse would be informed. Later that morning, the nurse was called to the resident’s room and found the resident unresponsive, with CPR initiated and a code blue performed by EMS, and the resident was pronounced dead. Additional interviews and documentation clarified that the nurse practitioner considered the information placed in the non‑emergent provider logbook inappropriate for that communication channel and stated that staff should have called a facility provider and 911 immediately regarding the resident’s status, rather than using the non‑emergent log. The DON stated that the first time she was made aware of the situation was when the code blue was called and that staff were required to notify a provider for any change in condition; review of the on‑call provider log showed no calls for this resident on the relevant dates. A CNA reported that when she arrived, the resident was not responding or opening her eyes, was coughing with gurgling sounds, and appeared very pale, and that she and another CNA could not obtain a pulse before summoning the nurse and initiating the code blue. The nurse who cared for the resident that morning stated she obtained but did not document vital signs, recalled an oxygen saturation of 88% on 2 liters improved to 92% on 3 liters, noted coughing with inability to expel mucus, and believed the resident was at baseline, so she did not call the on‑call provider and instead wrote in the non‑emergent log. The oncoming nurse stated she was told the resident was not awake or alert enough to receive morning medications, did not see the resident until notified by the CNA that the resident was not breathing, and stated that if a sternal rub was necessary, the nurse performing it should have called the provider. These actions and inactions led surveyors to identify an Immediate Jeopardy related to failure to notify providers and representatives of changes in condition.
Removal Plan
- Provide change in condition (CIC) education to LPN and RN staff, including definition of CIC, appropriate communication to providers, nursing follow-up and documentation responsibilities, consequences of delayed intervention, and importance of timely notification/early recognition and intervention.
- Ensure all nurses on duty since the event receive the CIC education and understand their responsibility (DON/designee verification).
- Conduct an initial review of the non-emergent provider communication log process with the provider and administration team to clarify appropriate acuity of notifications.
- Require that changes of condition be reported directly to the provider; restrict the non-emergent log to non-emergent patient requests or medication refills.
- Update the non-emergent provider communication log form to reflect the revised process.
- Place the agency nurse who documented the progress note on administrative leave pending review of care.
- Conduct an in-person meeting with the agency nurse by two nurse managers to review documentation and provide one-on-one education regarding substandard care.
- Notify the agency of the event and investigation involving the agency nurse.
- Assess and document vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) on every resident in the facility.
- Have nurse managers conduct room-to-room visual inspections to verify proof of life and resident stability.
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