Manzano Del Sol by Purehealth
5201 Roma Avenue NE, Albuquerque, NM 87108 · For profit - Corporation · 117 certified beds · (505) 262-2311 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Jan 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $26,109 in federal fines (most recent 2025-08-11)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.3% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.7% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 0.9% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.7% | 2.0% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.5% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.3% | 11.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.5% | 14.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 98.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.7% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.3% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.6% | 14.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 66.1% | 86.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.0% | 22.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.9% | 15.7% | 12.0% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 104 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.8%CMS range 52.3–73.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 5.8–14.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 37.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 26.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 78.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 2.7–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 117 beds and averages 80.7 residents a day — about 69% occupied, or roughly 36 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.69 hrs/resident/day on weekends vs 4.25 on weekdays — 13% thinner on weekends. RN hours go from 1.04 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-08-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross reference to F756. Based on record reviews and interviews, the facility failed to keep a resident free from significant medication errors for 1 (R #25) of 1 (R #25) resident, when staff entered a duplicate medication order of clopidogrel (an antiplatelet; medication that prevents blood clots by preventing platelets in the blood from sticking together) and administered the clopidogrel for a period of 19 consecutive days. This deficient practice had the potential to cause severe complications including but not limited to severe bleeding and death. The findings are: A. Record review of Antiplatelet Drug Toxicity (when a drug causes harmful effects to the body due to various reasons such as overdosing), published in National Library of Medicine (NLM) and dated 06/12/23, revealed Antiplatelet Drug Toxicity can cause the following complications: - Intracranial hemorrhage (a life-threatening bleeding that occurs inside the skull when a blood vessel ruptures or leaks). - Gastrointestinal hemorrhage (blood loss…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide quality of care for 1 (R #1) of 1 (R #1) resident reviewed for dehydration and nutrition when: 1. Staff failed to identify the decrease in nutritional intake and weight loss for R #1 as a change in condition. 2. Staff delayed to send R #1 to the hospital for two days after significant change in vitals. These deficient practices likely resulted in R #1's admission to the hospital with dehydration, urinary tract infection and sepsis (severe infection). The findings are: A. Record review of R #1's face sheet indicated she was admitted on [DATE] with the following diagnoses: - Fetal alcohol syndrome (condition in a child that results from alcohol exposure during the mother's pregnancy), - Severe intellectual disabilities [intelligence quotient (IQ) below 70 and deficits in at least two adaptive behaviors that affect everyday, general living], - Urinary tract infection, - Retention of urine (not fully draining urine from your bladder), - Dysphagia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete and submit a Five-Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of abuse for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot ensure the residents are safe and free of abuse. The findings are: A. Record review of the facility's Reportable Incident, dated 09/15/25, revealed the facility submitted a report for resident-to-resident abuse to the State Survey Agency. B. Record review of State Agency's incident tracking system revealed the State Agency received an initial incident report, dated 09/15/25, from the facility regarding resident-to-resident abuse.C. Record review of facility's records revealed the records did not contain documentation to show the facility submitted a Five-Day Report to the State Survey Agency.D. On 12/12/25 at 2:37 pm during an interview, the Administrator stated she was not able to locate the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-08-11 · tag F0841 — widespreadDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Cross reference to F756, F868 and F880. Based on record review and interviews, the facility failed to ensure the Medical Director (MD) participated in the Quality Assurance and Performance Improvement (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients), the Infection Prevention and Control Program (IPCP, a set of strategies and practices designed to prevent and control the spread of infections in healthcare settings), and the Medication Regimen Review (MRR) program. This failure had the potential to affect all residents at the facility. If the MD does not participate in QAPI, Infection Control, and MRR to assist in identifying, prioritizing, and correcting quality deficiencies, then the facility cannot ensure quality of care and services are consistently monitored and improved. The findings are: A. On 08/06/25 at 11:15 am, during an interview, the Nurse Practitioner stated she reviewed the facility's monthly MRRs. She stated she did not consult the Attending Physician when she responded to and acted on the Pharmacist's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-08-11 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement/Quality Assurance and Assessment (QAPIQAA) Committee meetings, as required by regulation. This failure had the potential to affect all residents. If the facility does not ensure required members, including the Medical Director (MD), participate in the QAPI/QAA Committee, then the committee may not fully meet regulatory requirements for oversight of quality issues. The findings are:A. Record review of the facility's QAPI Program policy, revised September 2024, stated the QAPI/QAA Committee met monthly to review reports, evaluate data, and monitor QAPI activities. Committee membership included the Administrator, Director of Nursing, Medical Director, and at least three other staff members from different disciplines. The committee was responsible to identify quality deficiencies, develop corrective actions, and ensure ongoing compliance. B. Record review of the facility's QAPI plan, dated January 2025, showed the MD was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-08-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure an effective Infection Prevention and Control program (IPCP, a set of strategies and practices designed to prevent and control the spread of infections in healthcare settings) when the facility's Medical Director (MD) failed to attend the scheduled infection control monthly meetings or be part of the program. This failure had the potential to affect all residents. If the MD does not participate in the facility's infection control program, then residents may be at an increased risk of infections due to a delay in identification and response of outbreaks. The findings are: A. Record review of the facility's Infection Control Online Meeting Invitations, dated 01/28/25, 02/04/25, 02/25/25, 03/25/25, 04/22/25, 05/27/25, and 07/16/25, revealed the MD did not participate in any of the meetings. B. On 08/08/25 at 11:04 am, during an interview, the Infection Control Preventionist (ICP) stated he worked for the facility for nine months and did not meet the MD at any of the Infection Control Meetings. The ICP stated he was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hazardous chemicals were stored securely and remained inaccessible to 4 (R #13, R #41, R #46 and R #55) out of 4 (R #13, R #41, R #46 and R #55) residents. If hazardous chemicals are left unattended and accessible to residents with significant cognitive impairments, then residents are at risk for accidental ingestion, misuse, or chemical contact injuries, which can result in serious harm. The findings are: A. Record review of the facility's Hazardous Areas, Devices and Equipment policy (dated 08/12/25) stated the following:- Hazardous areas, devices, and equipment in the facility would be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.- Hazardous areas included access to toxic chemicals.-Any element of the resident environment that has the potential to cause injury and was accessible to a vulnerable resident was considered hazardous.- Vulnerable residents would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-11 · tag F0790 — failed to provide dental care — patternProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide routine and emergency dental services for 2 (R #4 and R #48) of 2 (R #4 and R #48) residents. If the facility does not ensure residents with identified dental pain are referred for prompt evaluation and treatment, then residents are at risk for unresolved oral pain, infection, poor nutrition, and overall decline in health and quality of life. The findings are: R #4 A. Record review of R #4's face sheet showed she was admitted to the facility on [DATE] with a diagnosis of stage three chronic kidney disease and type two diabetes. B. On 08/05/25 at 10:38 AM, during an interview, R #4 stated she did not have a dental appointment in a long time. She stated she was supposed to have dental appointments every six months, because she was on dialysis (a medical treatment which filters waste and excess fluid from the blood). C. On 08/06/25 at 2:15 PM, during an interview, Social Services stated she did not have anything to do with making any type of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure residents maintained a dignified existence when staff failed to assist a resident with arranging grooming services for 1 (R #50) of 1 (R #50) resident reviewed for resident rights. This deficient practice limits the residents' ability to maintain dignity, personal appearance, and quality of life and had the potential to affect all residents who relied on facility staff to arrange grooming services. If the facility fails to assist residents in arranging grooming services, this could impact the resident's dignity, potentially leading to or worsening depression. The findings are: A. Record review of the facility's Resident Rights policy, revised August 2024, stated the residents had a right to privacy, dignity, and self-determination in their care. B. Record review of facility's Dignity Policy, undated, revealed the following:- Each resident shall be cared for in a manner which promoted and enhanced his or her sense of well-being,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's current advanced directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #7) of 1 (R #7) resident. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #7's Face Sheet, undated, revealed the following: -admission date of 11/18/2022.-Resident was a Full Code (attempt resuscitation). B. Record review of R #7's Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves), dated 04/18/2024, revealed the following: - Code status of do not resuscitate (DNR; lifesaving measures are not desired). - Comfort measures.- Do not transfer to hospital unless comfort needs cannot be met in current location.- Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. C. Record review of R #7's Progress Notes,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-11 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 1 (R #66) of 1 (R #66) resident, when staff failed to ensure the resident's as needed (PRN) alprazolam (anti-anxiety medication) was prescribed for a limit of 14 days, unless there was documentation in the resident's medical record of the rationale to extend beyond 14 days. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).The findings are:A. Record review of the facility's Medication Review Regimen (MRR) policy, undated, revealed the following:- The consultant pharmacist reviewed the medication regimen of each resident at least monthly.- Resident-specific irregularities resulting from or associated with medications were documented in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #77) of 1 (R #77) resident. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect. The findings are:A. Record review of R #77's Face Sheet revealed an initial admission date of 06/20/25 with the following diagnoses:- Cardiomyopathy (heart disease),- Type 2 diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar),- Unspecified Dementia (a group of conditions characterized by impairment of at least two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · Dcited before2025-08-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 2 (R #6 and R #23) of 2 (R #6 and R #23) residents. If staff do not complete an accurate assessment of residents, then staff may not provide adequate care and treatment of the resident's needs. The findings are: R #6 A. Record review of R #6's Face Sheet, undated, revealed the following: -Resident admission date of 06/14/2023.-Primary diagnosis of Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior).-Diagnosis of atrial fibrillation (A-Fib; irregular heart rhythm). B. On 08/07/25 at 1:29 PM, during an observation, revealed R #6 had missing and broken teeth. C. Record review of R #6's Care Plan, dated 02/12/24, revealed oral care was not care planned. D. Record review of R #6 annual MDS, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-11 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for 1 (R #73) of 1 (R #73) resident. If the facility fails to implement a complete baseline care plan within 48 hours of admission for residents, then the resident may be at risk of serious falls, hospital transfers, and worsening of clinical status. The findings are: A. Record review of the facility's Care Plans- Baseline Policy, dated 08/2024, revealed a comprehensive care plan may be used in place of the baseline care plan, provided the comprehensive care plan was developed within 48 hours of the resident's admission. B. Record review of R #73's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:- Muscle weakness (reduction in the power exerted by muscles),- Unsteadiness on feet (a lack of stability or coordination while walking or standing),- Cognitive communication deficit (difficulties in communication),- Need for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement resident focused, comprehensive care plans to address the oral hygiene needs for 1 (R #6) of 1 (R #6) resident. This deficient practice is likely to place the residents at risk for inadequate routine dental care, pain, infection, and complications to underlying conditions and prescribed medications. The findings are:A. Record review of R #6's Face Sheet, undated, revealed the following: -Resident admission date of 06/14/2023. -Primary diagnosis of Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior). -Diagnosis of atrial fibrillation (A-Fib; irregular heart rhythm). B. On 08/09/25 at 11:35 AM, during an observation, R #6's front teeth were missing. C. Record review of R #6's Progress Notes, dated 04/08/25, revealed the following: -Staff did not perform oral care for the resident. Resident independent in oral care. -The resident experienced disorganized thinking. -The resident had severe cognitive impairment. D. Record of R #6's Progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-11 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross reference to F760 and F605. Based on record reviews and interviews, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #66) of 1 (R #66) residents reviewed for unnecessary medications when the Attending Physician (AP) and the Medical Director (MD) failed to review, respond to, and act on the Consultant Pharmacist (CP)'s identified irregularities (the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and that impedes or interferes with achieving the intended outcomes of pharmaceutical services) sent monthly via Medication Regimen Reviews (MRRs, pharmacy review of the medication a resident receives). If physicians do not review, respond to, and act on CP's identified irregularities, then it could result in adverse consequences related to medication therapy. The findings are:A. Record review of the facility's Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interviews, the facility failed to: - Ensure resident refrigerators were maintained in a clean and sanitary condition. - Label and date food items in the refrigerators. This failure had the potential to affect 1 (200-unit ) out of 1 (200-unit) unit refrigerators. If the facility does not maintain refrigerators in a safe and sanitary manner, then residents are at risk of consuming spoiled or contaminated food, which could result in foodborne illness or decline in health.The Findings are:A. Record review of the facility's policy titled Food Storage and Sanitation, revised April 2024 ,revealed the following:- All food items stored in resident refrigerators were to be labeled and dated upon placement.- Refrigerators would be cleaned on a scheduled basis and kept free of spills, grime, and food residue.- Staff were responsible for monitoring to ensure food storage and appliances remained sanitary and safe for resident use. B. On 08/05/2025 at 8:30 AM, during an observation, the interior of the 200-unit resident refrigerators located in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #1) of 1 (R #1) residents reviewed for accurate MDS Assessments. If resident assessments are not complete and accurate, the facility could misidentify clinical complications and fail to provide adequate care to treat the resident's medical condition. The findings are: A. Record review of R #1's admission MDS, dated [DATE], indicated the resident did not have any pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) upon admission. B. Record review of R #1's progress notes, dated 05/26/24, revealed R #1 had a pressure ulcer to coccyx (tail bone) which measured 2 centimeters (cm) by 1.4 cm by 0.2 cm on admission. C. Record review of R #1's progress notes, dated 06/06/24, revealed R #1 had a stage 3 pressure ulcer (full thickness skin loss that extends…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to prevent an accident and to provide a safe transfer when the facility failed to: 1. Ensure beds were locked. 2. Ensure staff used equipment correctly 3. Ensure staff supervised residents needing help during transfers. 4. Ensure staff used the lift properly and with the appropriate equipment. These failures had the potential to affect 4 (R #5, R #21, #34, and R #58) out of 4 (R #5, R #21, R #34, R #58) residents reviewed for falls. These deficient practices could likely result in the residents falling and injuring themselves. The findings are: Findings for R #21 A. Record review of the face sheet for R #21 revealed the resident was admitted to the facility on [DATE] with multiple diagnoses to include: - Hypotension (low blood pressure), - Anemia (deficiency of healthy red blood cells in blood and they carry oxygen to all parts of the body), - Depression (sadness and loss of interest), - Malnutrition (not taking enough calories). B. Record review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-10 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to: 1. Ensure expired supplies were not kept with unexpired supplies. 2. Ensure staff documented the medication refrigerator temperatures. These deficient practices are likely to result in all 11 residents who resided on the 100 hall, as identified on the census list provided by the Executive Director (ED) on [DATE], to have expired supplies that have lost either their potency or effectiveness used on them, or to receive medication that has lost either their potency or effectiveness. The findings are: Ensure expired supplies were not kept with unexpired supplies. A. On [DATE] at 9:25 am, observation of 100 hall medication room revealed a Medstream dressing change kit expired on [DATE]. The expired supplies were stored with other non-expired supplies and not in the area used for the disposal of expired supplies. B. On [DATE] at 9:30 am, during an interview, medication technician (MT) #1 confirmed the supplies were expired. MT #1 stated it was expected the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, and observation the facility failed to ensure residents received appropriate treatment and services to prevent decrease in range of motion and mobility to the extent possible, for 1 (R #26) of 4 (R #2, R #26, R #36 and R #13) residents reviewed for range of motion and mobility, when they failed to provide a restorative nursing program [a nursing service with the goal to maximize function and prevent functional decline in residents who require assistance from staff for mobility and activities of daily living (ADLs)] for residents with limited range of motion and/or mobility. This deficient practice could likely result in residents' decreased ability to participate in ADLs and thus failing to reach their highest practicable level of wellbeing. The findings are: A. Record review of the Journal of the American Medical Directors Association's article titled, Contractures in Nursing Home Residents, dated February 2010, stated Contractures are highly prevalent but preventable in nursing homes. It further stated Contractures will get worse over time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-01-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store food under sanitary conditions by not ensuring food stored in refrigerators were covered, labeled, dated, and not expired. This deficient practice is likely to affect all 59 residents listed on the facility census provided by the administrator on 01/23/23. If the facility fails to adhere to safe food handling practices, then residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 01/23/23 at 8:48 am during an observation of kitchen refrigerators revealed the following: 1. One uncovered metal container labeled egg salad dated 1/12/23 - good through 1/20/23. 2. One covered metal container labeled chili dated 1/17/23 good thru 1/20/23. 3. One covered unlabeled metal container with some kind of white sauce dated 1/17 good thru 1/22. 4. One uncovered and unlabeled metal container with some kind of breaded wraps dated 1/11. 5. One covered and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-27 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents had accurate and complete advanced directives (a written statement of a person's wishes regarding medical treatment) on file for 2 (R #22 and R #52) of 4 ( R #22, R #40, R #52, and R #210) residents reviewed. This deficient practice could likely result in residents receiving a response and/or treatment that is not to their preference during a medical emergency. The findings are: Resident #22 A. Record review of R #22's EHR (Electronic Health Record) revealed that his code status (the type of emergent response and treatment a person would receive if they were experiencing a situation that would result in death) to be CPR (Cardiopulmonary Resuscitation is a type of treatment and response to provide and restore blood circulation and breathing). Further review of his NM MOST New Mexico Medical Orders for Scope of Treatment- a document that is reviewed by the resident and physician that allows the resident to indicate what type of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-27 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to create an accurate Baseline Care Plan within 48 hours of admission for 1 (R #11) of 4 (R #'s 8, 11, 17 and 42) residents reviewed for Baseline Care Plans. If the facility fails to include care, treatment, services, and goals the residents may not receive the appropriate care. This deficient practice could likely result in a decline in the residents condition due to staff not being aware of needed care and/or residents not being able to attain or maintain their highest practicable level of well-being. The finding are: A. Record review of Face Sheet dated 12/12/22 for R #11 revealed an initial admission date of 08/11/22 and included the following diagnoses: Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Obstructive and Reflux Uropathy (condition in which the flow of urine is blocked and causes urine to back up and injure the kidneys), Chronic Prostatitis (inflammation [swelling] of the prostate [male reproductive organ] that lasts for at least 3 months), Abdominal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-27 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement (put into place) a comprehensive person-centered care plan for 2 (R #s 11 and 49) of 4 (R #s 8, 11, 40 and 49) residents reviewed for care plans. This deficient practice could likely result in staff's failure to understand and implement the needs and treatments of the residents. The findings are: Resident #11 A. Record review of Face Sheet dated 12/12/22 for R #11 revealed an initial admission date of 08/11/22 and included constipation (difficulty clearing the bowels) as a diagnosis. B. Record review of Care Plans dated 12/13/22 for R #11 revealed no comprehensive care plan for constipation. C. On 01/27/23 2:22 pm during an interview, the Director of Nursing (DON) confirmed that there was no comprehensive care plan for R #11 addressing constipation. She further stated that there should have been a care plan to address this issue and acknowledged that R #11 was admitted to this facility with a diagnosis of constipation. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-27 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to: 1. Ensure that expired medications were not being stored with unexpired medications on the second floor inside of the medication storage room. 2. Ensure that products used to clean and disinfect surfaces were not expired. This deficient practice is likely to negatively impact the health of all the residents on the second floor by receiving expired medications could likely result in residents receiving medications that have lost their potency and effectiveness leaving them vulnerable to acquiring infections. Using expired products to clean and disinfect patient care areas can leave residents vulnerable to acquiring infections due to ineffective of the expired products. The findings for the second-floor medication room are: A. On 01/24/23 at 10:00 AM during observation of the second floors medication storage room, the following was observed: 1. One 8oz [ounce] bottle of Pepto- Bismol (This medication is used to treat occasional upset stomach, heartburn, and nausea.) which expired on 01/10/23 was found inside a cabinet in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-27 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to prevent misappropriation of resident money, when money wasn't deposited onto R #14's debit card and money was taken by staff for one resident (R #14) of 3 (R #14, 26 and 49) residents looked at for misappropriation/missing of property. This deficient practice could likely cause residents to feel unsafe, not trust the staff at the facility, and to experience anger and frustration. The findings are: Resident #14 A. Record review of the Minimum Data Set (MDS) completed on 11/20/22 indicated that resident had a BIMS (Brief Interview for Mental Status) of 14. The total possible BIMS score ranges from 0 to 15. 13 -15: cognitively intact. 8 -12: moderately impaired. 0 - 7: severe impairment. B. On 01/24/23 at 3:50 pm during an interview with the Administrator (ADM), ADM indicated that when he found out about the missing money/card in November which was $100 dollars and it went missing on 09/30/22, he stated that the BOM (Business Office Manager) and R #14 came to him to tell him about the missing money. He stated that Activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to complete a revised care plan to include interventions for 1 (R #48) of 1 (R #48) resident who was receiving renal dialysis (process of removing waste products and excess fluid from the body). This deficient practice could likely result in residents not receiving the care and services needed for renal dialysis. The findings are: A. Record review of R #48's Face Sheet revealed, admission date 02/01/22, Diagnosis: dependence on renal dialysis. B. Record review of R #48's physician's order for Dialysis to begin on 05/19/22. C. Record review of R #48's Care Plan dated 02/02/22 and a revised date 05/19/22 revealed, no intervention documentation for scheduled days/times that resident will be going to dialysis to receive services. D. On 01/25/23 at 9:33 am, during an interview with R #48, she stated that she goes on a weekly basis to dialysis on Tuesday, Thursday, and Saturday for 4-hour sessions. E. On 01/25/23 at 10:03 am, during an interview with Director of Nursing (DON), she confirmed that R #48's care plan did not have any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that the facility was free from accident hazards for 1 (R #19) of 1 ( R# 19) resident by having a bed side table placed on top of a fall mat (thick padded floor mat for the prevention of injuries due to falls from beds ext .). This deficient practice could most likely result in harm from injuries if resident was to fall from his/her bed. The findings are: A. Record review of R #19's face sheet initial admission date 02/26/16, diagnosis: hypertension (high blood pressure), constipation (difficulty in emptying the bowels), type 2 diabetes with plyneuropathy (high blood sugars with nerve damage), atherosclerotic heart disease (hardening of the arteries), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), disorders of bone density and structure (bone mineral density and bone mass decreases, structure and strength of bone changes), polyosteoarthrities ( joint disease in which arthritis affects five or more joints), post traumatic stress disorder, (a disorder in which a person has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that oxygen tubing was changed and dated for 2 (R #35 and R #210) of 2 (R #35 and R #210) residents reviewed for oxygen care. This deficient practice could likely result in residents using old or contaminated oxygen tubing. The findings are: Resident #210 A. On 01/23/23 at 11:42 am, during an observation of R #210's oxygen tubing, it was observed that the oxygen tubing was not dated (making it unclear or unknown when it was last changed) B. Record review of the EHR (Electronic Health Record) revealed that R #210 was admitted to the facility on [DATE] with the following pertinent diagnosis: chronic obstruction pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure with hypoxia (a condition where the lungs are unable to effectively exchange oxygen with carbon dioxide leading to consistently low levels of oxygen in the tissues), and pulmonary fibrosis (scar tissue…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-27 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure that medications were administered as ordered for 1 (R # 28) of 10 (R #'s 3, 6, 13, 18, 28, 33, 36, 42, 44, and 51) residents reviewed for medication administration, as ordered by the physician. This deficient practice can result in a resident failing to obtain maximum wellness and/or suffering prolonged illness. The findings are: A. On 01/24/23 at 2:34 pm during observation of medication administration, Registered Nurse (RN) #3 was observed providing medications to R #28. She was observed crushing all ordered medications and mixing them with applesauce prior to administering them. B. Record review of physician orders for R #28 dated 01/03/23 revealed that there was no order to crush medications. The current order, which was dated 11/17/22, from Hospice is as follows: Please continue current medications unless otherwise indicated. C. On 01/24/23 at 2:48 pm during interview with RN #3, she confirmed that R #28 did not have an order to crush medications at this time. She further stated she crushed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-27 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Therapy Department of a referral for 1 (R #40) of 3 (R #14, R #40, and R #48) residents reviewed for PT, OT, and ST (PT- physical therapy is the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise. OT- occupational therapy is a form of therapy that encourages rehabilitation through the performance of activities required in daily life. ST- speech therapy is a form of therapy to improve speaking and swallowing). This deficient practice could likely result in residents not receiving therapy services as requested to improve or maintain their physical functional ability. The findings are: A. Record review of New Mexico complaint #60331 revealed Member's POA [Power of Attorney] stated nursing facility is not providing the recommended therapies . B. Record review of EHR (Electronic Health Record) revealed that R #40 was admitted to the facility on [DATE] with the following pertinent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-27 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to consistently document tube feedings (is a medical device used to feed a person who is unable to eat or drink) on the Medication Administration Record for 1 (R #2) of 1 (R #2) resident looked at for tube feedings. This deficient practice could likely cause confusion on who is caring for the resident and if that staff member is aware of where to find and document the care they are giving. The findings are: A. Record review of the Medication Administration Record order for January 2023 indicated the following: Enteral Feed Order every shift Jevity 1.2 cal,(fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 70 ml (milliliters)/hr (hour) for 20 hr and water flushes of 48 ml/hr for 20 hr start time 1300 (1:00 pm) to end time 9:00 am; 30 ml flushes before and after medication and 10 ml between medications. Start Date 03/03/22 at 700 am. B. Record review of the Medication Administration Record order for January 2023 indicated the following documentation: Day shift:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$26,109 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $11,367 — penalty dated 2025-08-11
- $14,742 — penalty dated 2024-05-10
- Medicare payment denial — starting 2025-10-21 for 27 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PUREHEALTH — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.5 | -2.5 vs chain |
| Health inspection | 1 of 5 | 3.1 | -2.1 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 4 of 5 | 4.6 | -0.6 vs chain |
The other 7 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MM OPS ALBUQUERQUE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2024 |
| KCCJ1 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 11/01/2024 |
| LBEI HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 11/01/2024 |
| OVERHEAD OPS INVESTMENTS III LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2024 |
| BELL, KEVIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 11/01/2024 |
| CAMPION, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 11/01/2024 |
| MANAGEMENT MCOA LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
| SANDERS, ABBY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
| STOLARCZYK, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
| LEGENDS III LLC | Organization | ADP OF THE SNF | — | since 11/01/2024 |
| LEGENDS PHARMACY III SERVICES LLC | Organization | ADP OF THE SNF | — | since 11/01/2024 |
| PPSG CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | — | since 11/01/2024 |
CMS files one row per role, so the 19 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NM
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Mexico Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 325074. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.