Guadalupe County Hospital
A rural emergency hospital in Santa Rosa, New Mexico 88435
117 Camino De Vida, Suite 100, Santa Rosa, New Mexico 88435. (575) 472-3417.
Watch and the shortlist are kept with a free account, on every device. Your watch list. CMS’s own record is on Care Compare.
The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 2 deficiencies cited in the last three years (needs attention)
- 12 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Jul 30, 2025: a standard inspection.
2 deficiencies cited in the last three years, 2 of them at condition level, the most serious.
2 deficiencies at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Jul 2025. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jul 30, 2025: standard inspection2 deficiencies
-
Provision Of Services.
The inspectors’ words, 468 words
“Provision of services. CFR(s): (a) The REH’s health care services must be furnished in accordance with appropriate written policies that are consistent with applicable state law. This Condition is not met as evidenced by: 49835 Based on record review and interview the facility failed to ensure staff followed policy in place for suicide assessments and interventions for 1 (P[patient] 8) out of 4 (P2, P8, P9, and P14) patients reviewed for presenting to the hospital with psychiatric complaints. This deficient practice could lead to patients presenting with psychiatric complaints being at increased risk for self-harm while in a hospital setting. The findings are: A. Record review of the facility’s Policy titled, “Suicide Assessments and Interventions,” dated 05/27/2025 stated, If the patient has a positive screen (suicidal), the clinical staff will assess suicide ideation (thinking about or planning suicide) and risk with the Columbia Suicide Severity Rating Scale (C-SSRS). There are 3 levels to this assessment Low Risk, Medium Risk and High Risk. High risk level is a patient that attempts suicide and requires continuous one on one observation (a person that sits with the patients and always watches the person to ensure the patient is safe and not self-harming). With documentation of what the patient is doing or where the patient is every 15 minutes and requires an inpatient behavioral health admission. B. Record review of P8’s chart revealed P8 came to the Emergency Department (ED) on 05/19/2025 at 6:52 pm with chief complaint, “Suicide Attempt.” There was no Columbia Suicide Severity Rating Scale assessment completed in the chart, there was no documentation of one-on-one observations, or every 15-minute documentation. P8 was transferred out via air to a higher level of care for the chief complaint of suicide attempt. C. During an interview on 07/28/2025 at 2:15 pm with S[staff] 4 (clinical) it was confirmed that P8 came to the ED with chief complaint, “Suicide Attempt.” S4 confirmed there was no Columbia Suicide Severity Rating Scale completed to assess the patients risk for suicide, there was no suicide precautions ordered such as one-on-one for patient monitoring or documentation every 15 minutes of the patients activity or suicide risk to keep the patient safe with no self-harming activity occurring. S4 confirmed that the staff did not put in place the intervention that would keep P8 safe from harm. D. During an interview on 07/30/2025 at 10:30 am with S6 (clinical) it was confirmed that patients that come into the ED with a Chief Complaint of suicide ideation or attempt were placed in the room in front of the nurse’s station, there is not a staff member assigned to the patient for one-on-one watch. The staff will watch the patients as they work, and S6 did confirm that a suicidal patient will be left unattended to care for other patients.”
-
Discharge Planning.
The inspectors’ words, 210 words
“Discharge planning. CFR(s): An REH must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and their caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and their treatment preferences, ensure an effective transition of the patient from the REH to post-discharge care, and reduce the factors leading to preventable hospital admissions or readmissions. This Condition is not met as evidenced by: 47302 Based on interview the facility failed to have a discharge planning process in place for any patient that presents to the hospital. This deficient practice could lead to increased hospital visits because patients don’t have access to discharge planning. The findings are: A. During an interview on 07/29/2025 at 12:45 pm with S(staff)3, clinical, they explained that discharge planning is managed by the nursing staff and the provider. B. During an interview on 07/29/2025 at 1:00 pm with S4, clinical, they explained that the facility does not have a discharge planner. C. During an interview on 07/30/2025 at 1:00 pm with S4, clinical, it was confirmed that the facility did not have a policy regarding discharge planning.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 30, 2025 | Standard inspection | 2 deficiencies cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “Data are shown only for hospitals that participate in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs.”
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “Data are shown only for hospitals that participate in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs.”
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified rural emergency hospital since Sep 1, 2023.
- Ownership: government - local.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Government - Local.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Jul 15, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- None of the deficiencies cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Jul 15, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Guadalupe County owns 100% directly since Jul 1, 2010.
- New Mexicare Inc. runs it.
- 2 owners or officers are people: Frankie E Tenorio (managing employee (on the payroll), 100%); Erasmo Bravo (corporate officer, 20%).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Jul 15, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Guadalupe County | Owns 5% or more directly | 100% | Jul 1, 2010 |
| New Mexicare Inc. | Runs it (operational or managerial control) | Jul 1, 2010 |
How does it compare nearby?
- No other hospital CMS lists is in Guadalupe County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
Sources
-
Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated yearly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q2_2026.csv).
Released Jul 15, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.