Based on observation, interviews, and record reviews, the facility failed to protect the residents from the potential for accidents and hazards when the facility:- Permitted residents, with independent smoking privileges, to keep smoking materials, to include lighters and cigarettes, in their possession and to take them to their rooms.- Failed to ensure residents who utilized supplemental oxygen did not take their oxygen tanks into the designated smoking area.These failures had the potential to affect all residents. If residents have smoking materials in their possession, then there is the potential to light cigarettes or start fires in the facility. If this occurred around supplemental oxygen, then the oxygen could ignite and feed the fire. …
F689 citations in New Mexico
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Mexico cites F689 less often than its own record predicts
0.66 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 F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F689 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 a safe environment and provide adequate supervision to prevent accidents for 1 (R #88) of 1 (R #88) residents reviewed when staff left R #88's bed in the highest position, and R #88 fell from the bed. This deficient practice likely resulted in R #88 sustaining a right femur fracture (long bone that connects the hip to the knee) and spinal compression fractures (a break in a bone in your spine) which required hospitalization. Failure to ensure residents' beds are maintained in the appropriate position while occupied increases the likelihood of avoidable accidents, and places residents at risk for serious injury, significant harm, and potential death.The findings are: A. …
Based on record review and interviews, the facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for 1 (R #1) of 1 (R #1) resident, when staff failed to:Verify R #1's transfer assistance needs to provide the supervision and assistance necessary to safely assist R #1 with a transfer from the bed to a wheelchair, which resulted in R #1 experiencing a fall to the floor with injury.This deficient practice is likely to result in residents experiencing avoidable accidents and increases the risk of serious injury and harm. The findings are: A. …
The short window
Recent years
| Year | Share of New Mexico citations | vs expected |
|---|---|---|
| 2023 | 2.33% | 0.47× |
| 2024 | 3.71% | 0.69× |
| 2025 | 3.65% | 0.66× |
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