This is a repeat deficiency from a complaint survey completed on 02/01/18. Based on record review and interview, the Facility Assessment failed to identify and describe what nursing resources were necessary to provide competent care for residents during day-to-day operations, where overall staffing was indicated as insufficient to meet each resident's needs for all 92 residents identified on the alphabetical resident census list provided by the Administrator on 03/29/18. These deficient practices resulted in three (3) immediate jeopardy (IJ) situations that were identified as resident neglect, Substandard quality of care issues and insufficient staffing with competent nursing concerns that negatively impacted the residents in this facility. The findings are: A. …
F838 citations in New Mexico
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F838 citations were recorded in New Mexico for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What New Mexico surveyors wrote
F838 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 staff interview, the facility failed to ensure the facility assessment was accurate and current. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could lead to the residents not receiving the care they need to reach their highest well-being. The finding are: A. Record review of the Facility Assessment revealed: The document is titled Facility Assessment Worksheet was dated 07/29/21. B. On 09/08/22 at 3:59 PM, during an interview, the Administrator stated that he did not have a revised Facility Assessment.
Based on record review and interview, the facility failed to conduct a facility assessment. This deficient practice could impact all 82 residents of the facility as reported on the Resident Census and Condition provided by facility administration on 06/18/18. This failed practice could lead to the facility not having enough trained staff to provide the services that the residents need to attain and/or maintain their highest practicable well-being. The findings are: A. Record review of documents provided at the time of entrance to the facility on [DATE] revealed there was no facility assessment included within these documents. B. …
What else New Mexico surveyors cite →
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