F658 in New Mexico. Pick another state for the same tag.
Against expectation — 2025
New Mexico cites F658 more often than its own record predicts
Versus expected share2.41×
2.41 times the share F658 takes of citations nationally.
Share of New Mexico citations4.29%
Of every deficiency written in New Mexico in 2025, this is the portion that was F658.
New Mexico4.29%
National1.78%
Share of all citations that were F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F658 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.
K · Immediate jeopardy, patternDecember 6, 2018
During an annual survey the following deficient practice was found to be Immediate Jeopardy:
1) R #3 had received an extra dose of [MEDICATION NAME] (anticoagulant medication) after already receiving a first dose that day from (MONTH) 22, (YEAR) -November 27, (YEAR); then again on (MONTH) 29, (YEAR).
2) IDON confirmed that the nurse taking new order on (MONTH) 21, (YEAR) did not discontinue old order.
3) No education or in-servicing had been given to nursing staff giving anticoagulation medication regarding discontinuation of medication upon receiving new orders from physicians. …
Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 4 (R#6, #9, #14 and #52) of 4 (R#6, #9, #14 and #52) residents by:
1. Not administering oxygen (O2) in accordance with the physician's orders [REDACTED].
2. Not administering medication in accordance with the physician's orders [REDACTED].
If the facility is not administering oxygen and pain medications as ordered, the resident is likely to not receive the therapeutic benefits as needed, actual harm occurred when R#6 failed to receive their pain medication, resulting in unmanaged pain. The findings are:
Findings for O2:
A. Record review of R #52's physician orders [REDACTED]. …
D · No harm, potential for more than minimal, isolatedAugust 26, 2026
Based on record review and interviews, the facility failed to provide quality care that meets professional standards for 1 (R #12) of 3 (R #11, R #12 and R #18) resident reviewed, when staff failed to:Obtain a new set of R #12's vital signs (body temperature, pulse rate, respiration rate (rate of breathing), oxygen saturation (amount of oxygen in the blood), and blood pressure) after R #12 experienced a change in condition (CIC; any significant change in a resident's physical, mental, emotional, or functional health status that may require assessment, intervention, or communication with healthcare providers).Attempted to cancel an emergency medical services (EMS) response after R #12 experienced a medical emergency and was a do not resuscitate (DNR; lifesaving measures are not desired) . …
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