F865 in New Mexico. Pick another state for the same tag.
Against expectation — 2025
New Mexico cites F865 less often than its own record predicts
Versus expected share0.45×
0.45 times the national share — cited less often here than elsewhere.
Share of New Mexico citations0.11%
Of every deficiency written in New Mexico in 2025, this is the portion that was F865.
New Mexico0.11%
National0.24%
Share of all citations that were F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Mexico surveyors wrote
F865 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.
D · No harm, potential for more than minimal, isolatedMay 16, 2025
Based on observation and interview, the facility failed to identify quality deficiencies through their Quality Assurance and Performance Improvement Plan (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients) when staff were unaware the exit doors in the Memory Unit did not function as they were supposed to when the fire alarm was activated. This deficient practice is likely to affect all 118 residents, per census list provided by the Administrator (ADM) on 05/12/25. This deficient practice could likely result in staff and residents not able to safely evacuate the facility in case of emergency. The findings are:
A. …
C · No harm, potential for minimal, widespreadSeptember 13, 2018
Based on interview and record review the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that describes the process for conducting QAPI/QAA (Quality Assessment and Assurance) activities. This deficient practice had the potential to affect all 80 residents identified on the alphabetical list provided by the administrator residing in the facility by preventing the staff from identifying quality issues. The findings are:
A. On 09/13/18 at 8:31 am, during an interview with the Director of Nursing (DON) she stated the facility did not have a formal QAPI plan and provided an undated policy on Quality Assurance Philosophy Standards. She stated she is new to the facility and was not able to locate a QAPI plan. …
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