Based on record review and interview, the facility failed to ensure that an MDS assessment was completed every three months for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments when they failed to complete a quarterly MDS assessment within 92 days of the previous assessment reference date (ARD; the specific end point for the look-back periods in the MDS assessment process, also called the observation or assessment period.). This deficient practice could result in residents' assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #10's Significant Change MDS assessment revealed an ARD of 12/08/25. B. …
F638 citations in New Mexico
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Mexico cites F638 more often than its own record predicts
2.81 times the share F638 takes of citations nationally.
Of every deficiency written in New Mexico in 2025, this is the portion that was F638.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F638 findings written in New Mexico, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interview, the facility failed to ensure that an Minimum Data Set (MDS) was completed every three months for 4 (R #8, 11, 13 and 17) of 4 (R #8, 11, 13 and 17) residents reviewed for MDS assessments. This failed practice could result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: R #8 A. Record review of R #8's Quarterly MDS assessment dated [DATE] revealed that it was completed and signed on 07/15/18. B. Record review of R #8's Quarterly MDS dated [DATE] was reviewed on 11/11/18 but had not been completed or transmitted. R #11 C. Record review of R #11's Quarterly MDS assessment dated [DATE] revealed that it was completed and signed on 07/09/18. D. …
The short window
Recent years
| Year | Share of New Mexico citations | vs expected |
|---|---|---|
| 2023 | 0.12% | 0.55× |
| 2024 | 0.41% | 2.38× |
| 2025 | 0.32% | 2.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Mexico surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction