During an annual survey the following deficient practice was found to be Immediate Jeopardy: 1) R #17 had developed 2 facility acquired (developed in the facility) one that healed and one that progressed to a stage 4 pressure ulcer on her sacral (bony structure that is located at the base of the lumbar vertebrae) both discovered on 03/24/18. 2) Record review of R #17's care plan dated 03/22/18 revealed no interventions for her pressure ulcers, or her refusal to be laid in bed to relieve pressure on her wound. 3) Record review of a fax to R #17's Medical Doctor (MD) dated 04/21/18 requesting a Treatment Order for Santyl (Wound Care drug used to remove dead, damaged, or infected tissue to improve the healing potential) to treat R #17's stage 4 pressure ulcer. MD responded back on 04/23/17. …
F657 citations in New Mexico
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Mexico cites F657 more often than its own record predicts
2.41 times the share F657 takes of citations nationally.
Of every deficiency written in New Mexico in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F657 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, observation, and interview, the facility failed to ensure comprehensive care plans were revised for 4 (R #21, 76, 81, and 99) of 4 (R #21, 76, 81, and 99) residents reviewed for revision of care plans. This deficient practice has the potential for new interventions not to be put in place when a resident has a fall which could likely result in serious injury. The findings are: Resident #21 A. Record review of the facility face sheet dated 03/27/18 for R #21 revealed an admission of 03/27/18 with the following Diagnoses: [REDACTED]. …
Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #4 and R #5) of 6 (R #1, R #2, R #4, R #5, R #6, and R #11) residents reviewed when staff failed to update care plans to include the use of anticoagulant medications. This deficient practice is likely to result in the residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of the facility's Person-Centered Comprehensive Care Plan policy, revised on 11/04/25, revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment. R #4B. …
The short window
Recent years
| Year | Share of New Mexico citations | vs expected |
|---|---|---|
| 2023 | 3.79% | 1.77× |
| 2024 | 4.74% | 2.48× |
| 2025 | 4.51% | 2.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Mexico surveyors cite →
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