Cedar Ridge Inn
800 Saguaro Trail, Farmington, NM 87401 · For profit - Limited Liability company · 101 certified beds · (505) 598-6000 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $35,406 in federal fines (most recent 2025-08-27)
- about 23% of its spending goes to commonly-owned related companies
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 improved from 3 to 5 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 | 9.1% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.9% | 4.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 0.9% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.4% | 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 | 1.4% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.0% | 11.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.7% | 14.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.4% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.0% | 14.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.6% | 86.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.7% | 22.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.3% | 15.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.11 | 1.65 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.60 | 2.81 | 1.80 | better |
‡ 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.
57.7% 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 197 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.9% 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 107 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 57.7%CMS range 51.9–65.5 | 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 | 10.6%CMS range 8.1–13.8 | 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 | 72.9% | 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 | 62.6% | 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 | 75.7% | 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 | 97.6% | 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 | 95.8% | 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 | 97.5% | 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 | 0.8% | 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 | 7.1%CMS range 4.5–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 101 beds and averages 94.2 residents a day — about 93% occupied, or roughly 7 beds typically open. It runs fairly full. 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below 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 2.83 hrs/resident/day on weekends vs 3.27 on weekdays — 14% thinner on weekends. RN hours go from 0.39 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% 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 fewer than at the previous inspection — improving. 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2025-08-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 interview and record review, the facility failed to prevent the worsening of a pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #10) of 3 (R #10, #12 and #13) residents when staff failed to notify the physician when the resident's right gluteal fold (buttocks) wound worsened. If the facility does not recognize and notify the physician when a wound deteriorates, then the wound may worsen, become infected, and result in hospitalization. The findings are: A. Record review of R #10's face sheet revealed an initial admission date of 12/02/21 with a diagnosis of multiple sclerosis (MS; a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue). B. Record review of R #10's care plan, dated 09/09/24, revealed R #10 was dependent on staff assistance for all activities of daily living (ADL; 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.
- Actual harm · Gcited before2023-12-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 interview and record review, the facility failed to properly care for a pressure ulcer (an injury that breaks the skin and underlying tissues) for 1 (R #195) of 6 (R #9, R #16, R #35, R #40, R #194, and R #195) residents randomly sampled for pressure ulcer, when they failed to do the following: 1. Monitor redness before it became a pressure wound. 2. Implement preventative interventions including pressure relieving devices 3. Delay in initiating wound care treatment for 11 days upon the discovery of (2) wounds. 4. Not consistently treating the wound with ointment as ordered. These deficient practices likely resulted in the development of unstageable wound with infection requiring hospitalization. The findings are: A. Record review of R #195's face sheet identified that he was admitted on [DATE] and had the following diagnosis: Flaccid Hemiplegia (paralysis affecting one half of the body), Muscle Weakness and need for assistance with personal care. These are not all inclusive. B. Record review 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 · E2026-04-28 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to provide quality care that meets professional standards for 1 (R #2) of 3 (R #2, #3, and #7) residents reviewed, when staff: Discontinued an eye drop medication without a physician's order and authorization. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider, and potential complications. The findings are: A. Record review of R #2's face sheet revealed an admission date of 07/01/23 with the following diagnoses:Cerebral infarction (the death of brain tissue due to lack of blood flow),Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life),Glaucoma (a group of eye conditions that can cause blindness). B. Record review of R #2's physician orders revealed the following: Start date of 02/23/26, Dorzolamide HCI-Timolol Maleate PF (eye drops used to treat high eye pressure caused by glaucoma), instill one drop in the right and left eye, one time per day in the morning. Physician order 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 · D2026-04-28 · 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 interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, when: The facility did not provide continuous oxygen (O2) per physician's orders due to O2 equipment failure. If the facility fails to provide O2 per physician orders, then residents may receive substandard care and treatment, placing them at risk for preventable harm.The findings are: A. Record review of R #1's face sheet revealed an admission date of [DATE] with the following diagnoses:Fracture left femur (long bone that connects the hip to the knee),Chronic obstructive pulmonary disease (COPD; lung disease),Acute respiratory failure (low oxygen levels in the blood and can damage vital organs),Pulmonary fibrosis (scarring of the lung). B. Record review of R #1's nursing progress notes, dated [DATE], indicated R #1 was sent to the emergency room (ER) due to R #1 having abnormal vital signs (body temperature, pulse rate,…
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 before2025-08-27 · 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 — the official record, unedited, may be distressing
Based on observation, interview and record review the facility failed to secure an oxygen cylinder to prevent tipping and falling over for 1 (R #13) of 2 (R #13 and R #14) residents. If the oxygen container fell over, then the valve could break on the canister and cause the residual oxygen to leak or cause the oxygen cylinder to self-propel across the facility. The findings are: A. Record review of the facility's oxygen safety policy, last revised 2025, indicated oxygen cylinders will be properly chained or supported in racks or other fastenings (sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full or empty. B. On 08/26/25 at 10:35 am, an observation revealed R #13's oxygen tank sat unsecured next to her recliner. R #13 was not using the oxygen. C. On 08/26/25 at 10:35 am, during an interview, the Director of Nursing (DON) stated the portable oxygen container should not be in R #13's room. She stated oxygen cylinders should not be stored unsecured, because it could cause an accident.
- Potential for harm · Fcited before2025-02-21 · 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
Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manner for all residents who received food or drinks in the facility when staff failed to: - Keep the kitchen dust and grime free. - Ensure the ice machine drained through an air gap. These failures had the potential to result in cross-contamination and foodborne illness which could affect all residents who ate food from the kitchen. The findings are: Dust A. On 02/17/25 at 12:25 pm, observation of the kitchen revealed the following: - The wall and ceiling above the food preparation area were visibly dusty. - The deep fry area had visible dust and grime on it. - Vents near the food preparation area had dust and grime. - The kitchen staff prepared the residents' lunches below the visibly dusty ceiling. B. On 02/21/25 at 10:08 am, during an interview, the Dietary Supervisor (DS) stated staff should wash down the walls and ceiling to make sure that there was not any contamination. The DS stated it was over a year since staff washed down the walls and ceiling. The DS stated the deep fry area…
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 · E2025-02-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain a homelike environment for all residents who utilized the outdoor patio located outside the main dining room when staff failed to repair water damage to the building. Failure to make repairs to maintain a homelike environment could likely cause residents to feel like they do not matter. The findings are: A. On 02/19/25 at 12:41 pm, observation of the resident's outdoor patio, located off the main dining room, revealed the fascia (the exterior framing of the roof rafters) and soffit (the finish material visible beneath the roof's overhang on a building) located to the right (facing the door from the outside) was damage, with peeling paint and exposed wood with black substance. Further observation revealed the residents utilized the area for smoking, and the damage to the building was visible to the residents. B. On 02/19/25 at 12:25 pm, during an interview, the Maintenance Director stated he was responsible to inspect and maintain the building. The Maintenance Director stated he was aware of the condition 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 before2025-02-21 · 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 observations, record reviews, and interviews, the facility failed to maintain an environment that was free of potential for accidents when staff failed to: - Use footpedals when they propelled residents in their wheelchairs without the foot pedals attached for 2 (R #26 and R #3) of 2 (R #26 and R #3) residents reviewed - Maintain a resident courtyard free of sharp edges. This failure had the potential to affect all resident who utilized the enclosed courtyard. These deficient practices could likely create an unsafe situation and lead to serious injuries. The findings are: Wheelchair Foot Pedals R #26 A. Record review of R #26's current Face Sheet revealed R #26 was admitted to the facility on [DATE] with a diagnosis of muscle weakness. B. Record review of R #26's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/05/25, revealed the following: - A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 11, moderately…
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 before2025-02-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to: -Promptly identify a loss of a controlled medication (drugs or chemicals that the government regulates because they can be easily abused and lead to addiction.) for 1 (R #26) of 1 (R #26) resident. -The Director of Nursing (DON) did not notify the facility's pharmacist consultant of the lost controlled medication timely. These deficient practices are likely to lead to a delay in the incident investigation process and lead to potential drug misuse or diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use). The findings are: A. Record review of the facility's Controlled Medications-Administration Policy, dated 2024, revealed a physical inventory of all controlled medications should be conducted by two Licensed Nurses or one Nurse and a Certified…
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 · D2025-02-21 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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 interviews, the facility failed to provide a diet that met a resident's special dietary needs for 1 (R #249) of 1 (R #249) resident when staff failed to provide R #249 a salt free diet. This deficient practice is likely to lead to a buildup of fluid in R #249's body, causing him to have symptoms such as swelling in the legs, hands, and face, high blood pressure, shortness of breath, and potential complications like heart failure. The findings are: A. Record review of the facility's Liberalized Diets Policy, dated 2024, revealed staff were to serve residents a regular diet, unless a medical condition warranted a restricted diet. Staff were to monitor residents in relation to their conditions, their goals regarding nutritional status, and their physical, mental, and psychosocial well-being. B. Record review of R #249's electronic health record, undated, revealed R #249 was admitted to the facility on [DATE] with the following diagnoses: - Acute renal failure (sudden loss of kidney…
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 before2023-12-01 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 observations, interviews, and record reviews the facility failed to: 1. Ensure that opened insulin flex pen (pre-filed with insulin) were dated as to when they were opened by nursing staff. 2. Ensure expired supplies were not stored with unexpired supplies. 3. Document daily medication temperatures for refrigerator in medication room and medication carts, and medication room internal temperatures daily. These deficient practices could likely to result in all 89 residents that were identified on the census list provided by the Executive Director (ED) on [DATE] to receive expired or improperly temperature-controlled medications that have either lost their potency or effectiveness. The findings are: Findings for Opened insulin flex pen A. On [DATE] at 11:31 pm, during an observation of the Insulin Cart for the front of the facility, revealed R #3 had an insulin flex pen, Glargine insulin (is a long-acting insulin used to treat type 1 and type 2 diabetes in certain patients to improve and maintain blood…
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 before2023-12-01 · 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 serve food under sanitary conditions by: 1. Not dating food packages in kitchen refrigerators, freezers, and bulk dry goods bin; and 2. Not using proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. These deficient practices are likely to affect all 89 residents listed on the resident census list provided by the Administrator on 11/27/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to. The findings are: A. On 11/27/23 at 1:12 pm, during an observation of the kitchen, the deep chest freezer did not have any open dates or use by dates on the following frozen vegetables: -Five (5) bags of 2 lb. (pound) bag of fajita blend vegetable, -Four (4) bags of 2 lb. bags of brussel sprouts, -Six (6) bags of 2 lb. bags of corn and black bean blend, -Two (2) bags of 3 lb. crinkle cut zucchini squash, -Six (6) bags of 4 lb. yellow cut corn. B. On 11/27/23 at…
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 17 citations
- Potential for harm · F2023-12-01 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
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 staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect any of the 89 residents identified on the census provided by the Nursing Home Administrator (NHA) on 11/27/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and that can lead to resistance of multi-drug resistant organisms. The findings are: A. Record Review of the facility's infection control book revealed staff did not complete any documentation for: January, February, April, and May 2023. For March, June, July, August, September, and October only a list of residents on antibiotics was provided. Information in the antibiotic stewardship/infection control book should have included documentation related to which antibiotics were being used, what antibiotics were susceptible (having little resistance to…
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 · E2023-12-01 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Based on observation and interview the facility failed to treat residents with respect and dignity for 3 (R #9, R #14, and R #86) of 3 (R #9, R #14, and R #86) residents randomly identified when they failed to: 1. Ensure staff knock on the resident's bedroom door upon entering and 2. Ensure staff acknowledge residents upon entering their room and explain what service/care will be provided. These deficient practices could likely result in residents feeling unimportant and lack of having the privacy. The findings are: Findings for R #9: A. On 11/28/23 at 1:34 pm, during an observation, Certified Nursing Assistant (CNA) #7 entered R #9's room without knocking on the door or letting the resident know she would be entering the room with a Hoyer lift (a device used to safely transfer residents from one place to another). CNA #7 pulled the resident backwards in his wheelchair and did not explain why she was in his room and transferring to Hoyer lift. Findings for R # 86 B. On 11/28/23 at 8:30 am, during an interview, R #86 stated staff don't knock, they just barge into his room. C. On…
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 · E2023-12-01 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to provide accommodation of residents needs for 2 (R #5, and R #14) of 3 (R #5, R #14 and R #20) residents reviewed for call lights/ pressure pads within reach. This deficient practice is likely to result in residents being unable to request assistance, such as needing help with transferring, after falling, or other acute distress. The findings are: Findings for R #5 A. Record review of R #5's face sheet revealed a recent diagnoses of displaced comminuted fracture (a bone that is broken in at least two places) of shaft of right femur (thighbone) and unspecified fracture of upper end of right humerus (bone of the upper arm, forming joints at the shoulder and the elbow) with onset date of 11/21/23. B. On 11/28/23 at 1:25 pm, during an observation and interview, R #5 was in bed resting, she stated her leg hurt. R #5 attempted to use her call light but was unable to locate it. The call light pressure pad was partially covered by her comforter, at the foot of her bed, and out of her reach. C. On 11/28/23 at 1:31 pm,…
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 · E2023-12-01 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) documentation included a summary of the investigation and findings or conclusions regarding the resident's concerns for 19 (R #4, R #5, R #8, R #11, R #13, R #18, R #21, R #24, R #26, R #34, R #35, R #40, R #46, R #50, R #56, R #63, R #65, R #66, and R #69) of 21 (R #3, R #4, R #5, R #8, R #11, R #13, R #18, R #21, R #24, R #26, R #34, R #35, R #37, R #40, R #46, R #50, R #56, R #63, R #65, R #66, and R #69) residents reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and/or unsatisfied with the results of the grievance process. The findings are: A. Record review of a grievance book, a grievance filed by R #31 dated 11/07/2023, revealed the record did not contain a summary of the investigation and findings results. A grievance filed by R #69 dated 11/07/2023, did not include a summary of the investigation and findings. A grievance filed jointly by R #4, R #11, R #56, R #63, and R #65 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 · E2023-12-01 · tag F0659 — patternProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon observation, record review and interview, the facility failed to provide blood glucose monitoring (the use of a glucose meter for testing the concentration of glucose in the blood) for 2 (R #61 and R #200) of 2 (R #61 and R #200) residents and flushing a peripherally inserted central catheter line (PICC-a long, thin, flexible tube which is put into the arm to give chemotherapy and other treatments) for #61 by a qualified and trained nursing staff. This deficient practice could likely result in inaccurate glucose measurements, inaccurate treatments, and could lead to unnecessary accidents or injury. The findings are: Findings for R #61 A. Record review of R #61's face sheet revealed the following diagnoses: -diabetes mellitus (diabetes - a chronic medical condition where blood sugar levels are consistently high) due to underlying condition without complications, - acquired absence of right knee, presence of right artificial knee joint, and presence of other orthopedic joint implants. B. Email dated 11/01/23 from the New Mexico Board of Nursing stated that glucose…
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 before2023-12-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to maintain records of controlled substances (drugs that are subject to strict government control because they may cause addiction) on A, B and D medication cart. They failed to properly keep track of controlled substances kept in the medication carts. This deficient practice could cause the likelihood of a controlled substance being diverted (a medical/legal concept including the transfer of any illegal substance from the individual for whom it was prescribed a controlled substance from the individual for whom it was prescribed to another person for illicit use). The findings are: Narcotic (controlled substance) logbook A. On 11/27/23 at 1:28 pm, during an record review of A, B and D med (medication) carts narcotic book (is used to manually track inventory of prescription medications. Tracks resident prescription intake. It will record when the facility receives the medication for each schedule 2 controlled substances received by the pharmacy, and shift count at the beginning and end of each shift, the medication blister pill…
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 · E2023-12-01 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 record review and interview, the facility failed to ensure that medical records were complete and accurate for 3 (R #52, R #54 and R #83) of 4 (R #5. R #52, R #54 and R #83) residents reviewed for accuracy of documentation and written orders, and medication card matching the physcians orders. These deficient practices has the potential to negatively impact the continuum of care (continuum of care-a concept involving an integrated system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care), by staff misidentifying resident needs due to missing and inaccurate records. The findings are: A. Record review of the face sheet for R #54 revealed the following relevant diagnoses neurogenic bowel (loss of normal bowel [intestine] function), and chronic idiopathic constipation (a common functional bowel disorder characterized by difficult, infrequent, and/or incomplete defecation). B. On 11/28/23 at 11:11 am, during an interview, R #54 stated he had recently been hospitalized for a bowel obstruction…
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 · E2023-12-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 maintain proper infection prevention measures by: 1. Ensuring staff members wear appropriate PPE (personal protective equipment) while sorting contaminated laundry in the laundry room. 2. Disinfecting the glucometer correctly for 2 (R #61 and R # 200) of 9 (R #3, R #23, R #36, R # 42, R #61, R # 80, R #193, R #198 and R #200). 3. Not storing staff belongings in the medication cart. 4. Ensure safe transport of soiled laundry from resident rooms to the laundry room. Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 89 residents listed on the census provided by the Nursing Home Administrator (NHA) on 11/27/23. The findings are: Laundry Room: A. On 11/30/23 at 3:58 PM, during an observation and interview House Keeper (HK) #1 demonstrated the process she typically uses to sort the facility's soiled laundry including what PPE is used. HK #1 used a surgical face mask and standard exam gloves. When interviewed about this process, HK #1 stated that she uses…
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 · D2023-12-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 physician that Vancomycin (antibiotic medication used to treat serious, life-threatening infections by gram-positive bacteria that are resistant to less-toxic agents) trough level (measure of concentration of medication in the blood prior to the next dose to monitor for toxicity) was not checked prior to administering the next dose of the antibiotic for 1 (R #194) of 1 (R #194) resident. This deficient practice could likely cause toxic levels of Vancomycin to build up in the body of the resident leading to harm or death. The findings are: A. Record review of R #194's face sheet revealed he was readmitted on [DATE] with the following diagnoses: 1. Encounter for orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) aftercare following surgical amputation (removal of a limb) 2. Osteomyelitis, unspecified (infection of the bone) 3. Unilateral primary osteoarthritis (a type of degenerative joint disease…
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 · D2023-12-01 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure lab work (a process of collecting blood samples to determine therapeutic levels of medication is the body) was completed as ordered by the physician for 1 (R #194) of 1 (R # 194) residents randomly sampled. This deficient practice of not obtaining lab work could result in health concerns not being addressed timely and can cause health problems such as a Vancomycin Trough level (Peak and trough levels are usually monitored, Toxicity is best monitored by looking at lab values) toxicity to go unidentified. The findings are: A. Record review of Physician's orders dated 11/20/23 indicated the following order. Vanc trough, CMP (comprehensive metabolic panel, or chemical screen, a panel of 14 blood tests that serves as an initial broad medical screening tool), and CRP (blood test measures the level of C-reactive protein in your blood. A protein that is made in your liver and released into your bloodstream) draw one time a day on Monday and Thursday, thirty minutes prior to dose for six weeks. B. Record review of Electronic…
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 · F2022-09-09 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 a sanitary (clean) environment by allowing air pressure in the clean linen holding area of the laundry rooms to be negative [pressure inside an environment is less than the pressure of its surroundings resulting in a vacuum effect causing the air to flow in from the outside] to the adjacent [next to] hall. This deficient practice may likely result in decreased air quality in the clean laundry folding and holding area and contamination of the clean linen in the laundry area by any dust or dirt with contaminant particles [polluting/impure] in the hall. The findings are: A. Record review of the Centers for Disease Control website, (https://www.cdc.gov/hai/prevent/resource-limited/laundry.html) accessed on 09/14/22 at 3:30 pm, revealed Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items .Clean, uncovered/unwrapped textiles (type of cloth or woven fabrics) stored 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 · E2022-09-09 · 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 maintain a process of establishing an updated and valid advanced directive (a written statement of a person's wishes regarding their desire to receive medical treatment for prolongment of life or not) for 5 (R #'s 40, 69, 70, 76, & 234) of 5 (R #'s 40, 69, 70, 76, & 234) residents reviewed for advanced directives. This deficient practice could likely result in a resident not having their preferences honored during a life or death situation by not having the physician sign the form. The findings are: A. Record review of the New Mexico Medical Orders for Scope and Treatment website, last updated 07/27/20, found at https://www.nmmost.org/about revealed The NM MOST form is a bright green document that is completed by a healthcare provider after a conversation with a patient about their healthcare wishes. Once signed by an authorized healthcare provider and the patient (or the patient's legal healthcare decision maker, as appropriate), the NM MOST becomes a…
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 · E2022-09-09 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide an ongoing program of activities designed to meet the interests of residents and promotes well being for 2 (R #2 and 36) of 2 (R #2 and 36) residents reviewed for activities by, not identifying residents interests and providing meaningful individualized activities for the residents affected. This deficient practice could likely cause residents to experience boredom, feelings of isolation (the condition of being alone, especially when this makes you feel unhappy) and/or depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) by not enhancing their social and emotional well-being. The findings are: A. On 09/06/22 at 12:43 pm, during an interview with R #36 she revealed, we (residents) used to have a lot of fun here (at the facility), we would have a big picnic they (staff) would make it a big party and invite our families and their families and have all kinds of games. Now we have bingo and a game where they hit a balloon with a paddle. They have book games and coloring books 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 · E2022-09-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, interview, and record review,the facility failed to: 1. Maintain a process that would ensure that oxygen tubing was dated when changed for 5 (R#'s 59, 60, 70, 132 and 183) of 5 (R#'s 59, 60, 70, 132, and 183) residents reviewed for oxygen care and 2. Ensure humidifier bottles was labeled for 1 (R #60) of 1 (R #60) reviewed for oxygen care. These deficient practices could likely lead to confusion amongst the staff as to when the oxygen tubing and humidifier bottles are due to be changed to prevent infection as a result of unsanitary (dirty or unhealthy and therefore likely to cause disease) conditions. The findings are: Finding for R #59: A. On 09/07/22 at 11:32 am, during an observation of R #59's oxygen tubing; the oxygen tubing was not labeled with the date the tubing was last changed. Findings for R #60: B. On 09/06/22 at 3:56 pm, during an observation of R #60's oxygen tubing and oxygen concentrator (a type of medical device used for delivering oxygen to individuals with…
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 · E2022-09-09 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 the medication error rate did not exceed 5 percent by performing 2 medication errors out of 30 opportunities for error, resulting in an error rate of 6.67 percent. Medication errors were observed for 2 (R # 182 and 233) of 7 (R #'s 10, 16, 29, 55, 64, 182 and 233) residents by: 1. Failure to aspirate [pull back on] a peripherally inserted central catheter (PICC-a long IV that goes into a large vein by the heart) line to ensure it is in a vein, prior to flushing [pushing into with an ordered intravenous (IV) fluid] for R #182 and 2. Administration of the medication Tamsulosin [is used by men to treat the symptoms of an enlarged prostate {part of the male reproductive system that is located just below the bladder}] to R #233, which had been discontinued on 09/02/22. If medications are not administered correctly and as ordered, residents affected may likely experience worsening of their level of well being or lack of relief from…
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 before2022-09-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interview, and record review the facility failed to ensure all insulin [medication that regulates the body's use of food] was properly labeled for individual resident use. This deficient practice puts any resident receiving insulin from those vials at risk for being injected with a contaminated/possibly toxic dose of insulin. The findings are: A. Record review of the Centers for Disease Control website (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) accessed on 09/14/22 at 10:00 am revealed, Multiple-dose vials of insulin should be dedicated to a single person whenever possible. If the vial must be used for more than one person, it should be stored and prepared in a dedicated medication preparation area outside of the patient care environment and away from potentially contaminated equipment. B. On 09/07/22 at 11:42 am, during observation of a medication cart (referred to as the insulin cart, which was positioned next to the facility's central nursing desk) there were two multidose vials [bottles] of insulin that were open needle punctured…
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 · D2022-09-09 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 provide assistive devices for 1 (R #45) of 1 (R #45) residents reviewed during dining observation for adapted eating utensils. This deficient practice could likely result in residents being unable to consume their meals resulting in weight loss. The findings are: A. Record review of R #45 Physicians orders dated 08/23/22 revealed, Built-up utensils (are built up with a material to increase the surface area of the handle, which in turn provides greater grip over the adaptive dining aid), Diagnosis: frequency (scheduled): Continuous (starting 08/23/22). B. On 09/07/22 at 12:45 pm, during a random dining observation, R #45 was observed eating his meal without built-up silverware. Using a regular fork, and having difficulty using and holding the fork while eating. C. On 09/07/22 at 12:50 pm during an interview with R #45, he stated, I have trouble holding and using the regular fork they (staff) gave me. I'm supposed to have a built-up fork weighted around the handle. It's been a while since I have had a built-up…
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
$35,406 in federal fines across 2 penalties.
- $27,040 — penalty dated 2025-08-27
- $8,366 — penalty dated 2023-12-01
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| FARMINGTON OPERATIONS HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 03/31/2023 |
| O STREET OPERATIONS 2 LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 01/20/2025 |
| KATZ, AHRON | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/2025 |
| BROWN, LAWRENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2023 |
| GREENBERG, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2023 |
CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 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 23% 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.
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 325113. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-21, 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.