During a complaint survey, the following deficient practice was found to be Immediate Jeopardy: 1) R #3 had been admitted with a stage II pressure wound that healed and later developed a facility acquired Pressure wound (developed in the facility) that progressed to an infected (osteo[DIAGNOSES REDACTED] - infection of bone) stage 4 pressure ulcer (very deep, reaching into muscle and bone and causing extensive damage) on his left buttock (In the same area that had previously healed). 2) Record review of R #3's care plan dated 07/02/18 revealed vague interventions for his pressure ulcers to include a lack of timing for repositioning to prevent and/or heal pressure ulcers. 3) Record review of R #3's medical record revealed no documentation of when staff repositioned him. …
F656 citations in New Mexico
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Mexico cites F656 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in New Mexico in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F656 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 interview, observation and record review the facility failed to ensure that a comprehensive care plan for a gastrostomy tube (medical procedure in which a tube (G tube) is passed into a patient's stomach through the abdominal wall, for a means of feeding) and [MEDICAL CONDITION] (a surgical procedure in which an opening (stoma) is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall for stool to pass through) was developed for 1 ( R #3) of 4 ( R #1, #2, #3 and #4) residents reviewed for care plans. If the resident's care plan does not accurately reflect the resident's health status, treatment and interventions, residents may not get the care and treatment that they need. The findings are: A. …
Based on observation, record review, and interviews, the facility failed to accurately reflect R #5's use of dentures in the care plan for 1 (R #5) of 5 (R #5, R #7, R #8, R #10 and R #33) residents reviewed. This deficient practice is likely to result in residents' needs not being met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: A. Record review of R #5's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/12/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.2. R #5 was independent and required no assistance with oral hygiene. B. …
The short window
Recent years
| Year | Share of New Mexico citations | vs expected |
|---|---|---|
| 2023 | 3.43% | 0.95× |
| 2024 | 3.40% | 1.00× |
| 2025 | 3.22% | 0.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Mexico surveyors cite →
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