Based on observation, interview and, record review the facility failed to ensure there was a functional system in place to ensure staff could initiate /not initiate CPR (Cardiopulmonary Resuscitation lifesaving technique, aims to blood and oxygen flowing through the body) during an emergency for all 66 residents (residents were identified by the Resident Matrix provided by the Administrator on [DATE]), when they failed to: 1) Monitor the accuracy of resident's living will (legal document that helps communicate patient's wishes about medical treatment when they are not available to make their own wishes known ), 2) System for staff to immediately recognize the resident's code status (type of emergency treatment a person would or would not receive if their heart or breathing were to stop)… …
F678 citations in New Mexico
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Mexico cites F678 less often than its own record predicts
0.59 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 F678.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F678 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 there was a system in place for the nursing staff to immediately recognize the resident's code status in the electronic medical record; and to also ensure that the paper chart was on the same unit as the resident. This deficient practice affected 1 resident (R #1) out of 10 (R #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) residents residing in the facility, causing confusion among the nursing staff who was not aware of what R #1's code status was and made an assumption of resident being on hospice resulting in staff not initiating any life saving efforts when R #1 was found to not be breathing. The findings are: A. Record review of the face sheet revealed that resident had been diagnosed with [REDACTED]. …
Recite from complaint survey on [DATE]Based on record review and interview, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 3 (R #30, R #31, and R #46) of 3 (R #30, R #31, and R #46) residents reviewed for code status, when they failed immediately document R #30's, R #31's, and R #46's code status in their medical record. This deficient practice is likely to delay potentially lifesaving measures if staff are not immediately aware of residents' preferences for resuscitation. The findings are:R #30 A. …
The short window
Recent years
| Year | Share of New Mexico citations | vs expected |
|---|---|---|
| 2023 | 0.12% | 0.65× |
| 2024 | 0.21% | 0.98× |
| 2025 | 0.11% | 0.59× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Mexico surveyors cite →
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