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Desert Springs Health Care LLC

1701 N Turner Street, Hobbs, NM 88240 · For profit - Corporation · 80 certified beds · (575) 397-0870 Medicare & Medicaid certified

Call the home — (575) 397-0870 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0568)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$17,215 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0568)
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,215 in federal fines (most recent 2026-01-30)
  • about 26% 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.

5/5
CMS overall
5 of 5
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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1301 North Turner Street
Pharmacy
1225 N Turner St · (575) 393-2767 · Call to confirm hours
Grocery
Thriftway0.4 mi
1317 N Turner St · (575) 393-7022 · Call to confirm hours
Park
200 E Green Acres Dr · Typically dawn to dusk
Place of worship
100 E Berry Dr · (575) 393-4911

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 4 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 4 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.2%11.3%15.4%better
Long-stay residents who lose too much weight0.4%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%0.9%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.0%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened2.3%11.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.5%14.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.7%95.3%typical
Long-stay residents with pressure ulcers3.9%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control15.7%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.9%14.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine93.9%86.4%79.4%better
Short-stay residents rehospitalized after admission20.4%22.0%22.6%typical
Short-stay residents with an outpatient ER visit13.3%15.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.631.651.67typical
Long-stay outpatient ER visits per 1,000 resident days4.062.811.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

46.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.9%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
75.0%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 75.0% 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 28 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 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.9%CMS range 36.1–57.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.9–12.810.7%Oct 2022–Sep 2024no 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 discharge75.0%56.6%Oct 2024–Sep 2025CMS 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 discharge67.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.9%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge95.8%98.7%Oct 2024–Sep 2025CMS 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 stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.0–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 2022–Sep 2024CMS 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

0.53
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.36
RN hoursweekends
51.6%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 74.9 residents a day — about 94% occupied, or roughly 5 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.05 hrs/resident/day on weekends vs 3.78 on weekdays — 19% thinner on weekends. RN hours go from 0.60 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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

12
deficiencies at the latest standard inspection (2026-01-30)
2
at the previous standard inspection (2024-11-20)

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.

ABCDEFGHIJKL

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.

34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · Gcited before2026-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 for 1 (R #81) of 3 (R #4, R #37, and R #81) residents reviewed for falls when staff failed to provide the required assistance during personal care resulting in R #81 falling from her bed. This deficient practice resulted in R #81 sustaining a fractured (broke) femur (thigh bone) and a fractured finger. The findings are:A. Record review of R #81's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Chronic, systolic (congestive) heart failure (impaired heart function),2. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),3. Morbid (severe) obesity (severely overweight),4. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),5. Muscle weakness generalized (reduction in the power exerted by…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-05-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 Past Noncompliance: Compliance Date was 04/06/24. Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for falls, when the facility failed to: 1. Ensure beds were fully locked. 2. Ensure staff was familiar with equipment. These deficient practices resulted in R #1 falling and sustaining injuries that required treatment at the hospital. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Type 2 Diabetes. 2. Hyperlipidemia (high cholesterol). 3. Anxiety. 4. Heart Failure. B. Record review of R #1's nursing progress notes revealed the following: - On 03/21/24, staff documented the resident had a witnessed fall and landed face down. The resident fell out of bed while receiving a bed bath. Witness stated the resident did not lose consciousness when she landed on the floor. - On 03/22/24, staff documented that staff gave the resident a bed bath. When staff…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 provide respiratory care in accordance with professional standards for 3 (R #3, R #39, and R #91) of 4 (R #1, R #3, R #39, and R #91) residents reviewed for respiratory care when staff failed to:1. Ensure medical orders indicated when to administer supplemental oxygen (extra oxygen required to support the body's vital functions) needed to R #3 and R #39.2. Ensure a medical order was in place for R #91's supplemental oxygen use. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions. The findings are: R #3A. Record review of R #3's admission record revealed R #3 was admitted into the facility on [DATE] with the following diagnoses:1. Chronic Obstructive Pulmonary Disease (COPD; a progressive lung condition causing airflow blockage and breathing difficulties),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-30 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary 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 record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis for 2 (R #7 and R #11) of 5 (R #2, R #3, R #6, R #7, and R #11) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are: R #7A. Record review of R #7's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls),2. Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain),3. Atherosclerosis of coronary artery bypass grafts (plaque containing cholesterol and lipids that build up on artery walls),4. Type 2 diabetes mellitus (DM2, a condition that results…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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 implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not ensuring Enhanced Barrier (EBP) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) readily available for 2 (R #37 and R #91) of 7 (R #2, R #5, R #8, R #9, R #10, R #37 and R #91) residents reviewed. These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are:R #37A. Record review of R #37's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Focal traumatic brain injury (an external force causes localized damage to an area of the brain),2. Zoster (shingles),3. Elevated white blood cell count (typically means the body…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 residents were provided with a choice about aspects of his/her life that are significant to the residents for 1 (R #27) of 3 (R #3, R #27 and R #91) residents by not having a choice to refuse dietician orders. If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression.The findings are:A. Record review of R #27's admission record revealed R #27 was admitted into the facility on [DATE] with the following diagnoses:1. Traumatic subdural hemorrhage (SDH; often life-threatening brain injury involving bleeding typically caused during head trauma),2. Anemia (low red blood cell count),3. Retention of Urine (the inability to fully empty the bladder),4. Repeated falls.B. Record review of R #27's Quarterly [NAME] Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/12/26 revealed R…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 the resident's current advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law and relating to the provision of health care when the individual is incapacitated) and New Mexico Orders for Scope of Treatment (MOST) form (a document which provides an individual's wishes for emergency and lifesaving care) matched the order in the electronic health record (EHR) for 2 (R #5 and R #39) of 7(R #5, R #6, R #8, R #9, R #10, R #12, and R #39) residents reviewed for advance directives when staff failed to update the resident's code status. This deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred. The findings are:R #5A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's physician orders dated [DATE], revealed R #5 is 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · tag F0641 — isolated
    Ensure 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 complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #42) of 3 (R #2, R #3, and R #42) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.The findings are: A. Record review of R #42's admission record revealed he was admitted on [DATE].B. Record review of R #42's physician record revealed the following:1. An order dated 07/04/25 for Zoloft Oral Tablet (antidepressant medication) 100 milligrams (MG). Give 1.5 tablet by mouth one time a day for depression.2. An order dated 09/10/25 for Depakote Sprinkles (anticonvulsant medication) Oral Capsule 125 milligrams (MG). Give two capsules by mouth two times a day for dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with behaviors.3. An order dated 12/20/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0655 — isolated
    Create 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 review and interview, the facility failed to develop and implement a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours for 1 (R #11) of 6 (R #1, R #2, R #7, R #8, R #9, and R #11) residents reviewed for baseline care plans. If the facility fails to develop and implement a baseline care plan, then residents might not get the care and services they need. The findings are: A. Record review of R #11's admission Record revealed she was admitted to the facility on [DATE].B. Record review of R #11's Electronic Health Record (EHR) revealed no evidence of a baseline care plan.C. Record review of R #11's care plan revealed the care plan was developed and implemented on 10/27/25.D. On 01/30/26 at 4:16 pm, during an interview with the Director of Nursing (DON), she confirmed the facility failed to develop and implement a baseline care plan for R #11. The DON stated that she expects every resident 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #91) of 4 (R #2, R #3, R #42, and R #91) residents reviewed for care plans when staff failed to: 1. Develop a care plan to include interventions for R #91's use of oxygen.2. Develop a care plan to include interventions for R #91's use of floor mat.This deficient practice could likely result in proper care not being provided to residents.The findings are: A. Record review of R #91's admission record revealed R #91 was admitted into the facility on [DATE].B. Record review of R #91's care plan dated 01/25/26 revealed the following:1. There was no care plan to include intervention for the use of supplemental oxygen (extra oxygen required to support the body's vital functions),2. There was no care plan to include interventions for the use of a floor mat.C. Record review of R #91's current medical orders revealed the following:1. An order dated 01/29/26 for this resident to use…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 1 (R #3) of 5 (R #2, R #3, R #27, R #34 and R #55) residents reviewed when staff failed to revise the care plan to include the current use of oxygen interventions. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #3's admission record revealed R #3 was admitted into the facility on [DATE] with the following diagnoses:1. Chronic Obstructive Pulmonary Disease (COPD; a progressive lung condition causing airflow blockage and breathing difficulties),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),B. Record review of R #3's physician record revealed an order dated 08/14/25 for oxygen…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 provide adequate foot care services for 1 (R #77) of 1 (R #77) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. The findings are: A. Record review of R #77's face sheet indicated she was admitted on [DATE] with the following diagnoses: 1. Metabolic encephalopathy (brain dysfunction caused by metabolic disturbances in the body, leading to symptoms such as confusion, memory loss, and altered consciousness),2. Chronic kidney disease (a condition characterized by the gradual loss of kidney function over time, leading to the accumulation of waste and excess fluid in the body),3. Muscle weakness (generalized),4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),5. Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · D2026-01-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #6) of 5 (R #1, R #3, R #6, R #27, and R #55) residents reviewed, when the facility failed to document an updated consent ordered by physician. This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment. The findings are:A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE] with the following diagnoses:1. Type 2 Diabetes Mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),2. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),3. Anxiety (feelings of fear or apprehension),4. Dementia (a group of conditions characterized by impairment of at least two brain…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-20 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interview, the facility failed to ensure staff assessed residents who utilized bed rails for 5 (R #21, R #25, R #27, R #31, and R #39) residents review for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) for bedrails. If the facility fails to assess the resident's risk for entrapment, then residents are likely to experience injury by becoming trapped between the mattress and the bedrail. The findings are: A. Record reviews for the five residents who utilized bed rails revealed staff reviewed the risks and benefits of bed rails but did not complete bedrail assessments for the residents. B. Record reviews for the five residents who utilized bed rails revealed staff did not attempt to use appropriate alternatives to bed rails or determine if the alternatives met the residents needs by not completing bed rail assessments for the residents. B. On 11/20/24 at 12:16 pm, during an interview with the Director of Nursing (DON), she stated staff did not complete bedrail assessments. The DON…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to label food in accordance with professional standards of food service safety. This failure had the potential to affect all 74 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 01/22/24. If the facility fails to adhere safe food storage, residents are likely to be exposed to foodborne illnesses. The findings are: A. On 01/22/24 at 3:37 PM, during an observation of the kitchen revealed the following: 1. Yellow cake mix opened and not dated. 2. Original cheesecake filling opened and not dated. 3. Strawberry gelatin mix opened and not dated. 4. [NAME] cracker crumbs opened and not dated. B. On 01/22/24 at 3:44 PM, during an interview with the Dietary Manager, she stated the food items did not have open dates. The Dietary Manager stated the food should have opened dates to determine expiration dates.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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 provide quarterly statements for resident's personal funds entrusted to the facility for 1 (R #23) of 2 (R #23, and R #54) residents sampled for personal funds. If residents are not provided quarterly statements for their personal funds accounts, then residents could experience unnecessary anxiety or depression, because they are unaware of their finances. The findings are: A. On 01/23/24 at 12:29 PM, during an interview with R #23, she stated she did not receive any statements for her personal funds account that the facility handled. B. Record review of R #23's medical record revealed she was admitted on [DATE] and she did not have a designated power of attorney (legal authorization that gives authority to someone to act on behalf of the resident). C. On 01/26/24 at 11:51 AM, during an interview with the contracted business office manager, she confirmed that she did not send the quarterly statement to R #23. The BOM stated that she sent the statements…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 record review and interview, the facility failed to ensure residents, resident representatives, and Ombudsman received a written notice of transfer as soon as practicable for 2 (R #50 and R # 72) of 2 (R #50 and R #72) residents reviewed. This deficient practice could likely result in the resident and/or representatives not knowing the reason or location the resident was transferred or discharged or their options to appeal the transfer or discharge. The findings are: R #50 A. Record review of R #50's Electronic Medical Record (EMR) revealed the following: 1. R #50 was transferred to the emergency department on 12/03/23 for shortness of breath and returned to the facility the same day. 2. R #50 was transferred back to the hospital on [DATE] for altered mental status and returned to the facility on [DATE]. 3. The record did not contain documentation staff provided a written transfer notice to R #50 or to the Ombudsman. B. On 01/25/24 at 8:45 am, during an interview with the Social Services Director (SSD),…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 a written notice to the resident or resident representative that specified the bed-hold policy and the number of days the facility would hold a bed for the resident at the time of the transfer for 2 (R # 50, R # 72) of 2 (R # 50, R # 72) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or representatives being unaware of the resident's ability to return to their previous bed or the next available bed upon return from the hospital. The findings are: R #50 A. Record review of R #50's electronic medical record (EMR) revealed R#50 was transported to the hospital on [DATE]. The medical record did not contain evidence to show the resident or legal representative received notice of the bed-hold policy in writing at the time of transfer. R #72 B. Record review of R # 72's EMR revealed he was sent to the emergency room on [DATE] due to agitation. C. On 01/25/24 at 11:48 AM, during an interview, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0641 — pattern
    Ensure 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 the MDS accurately reflected the resident's status at the time of the assessment for 1 (R #37) of 3 (R #11, R #23, and R #37) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: A. Record review or R #37's physician's orders revealed a prescription for corrective lenses, dated 05/18/22. B. Record review of R #37's quarterly MDS, dated [DATE], revealed the record did not contain documentation R #37 had vision impairments or corrective lenses. C. On 01/23/24 at 10:19 AM, during an interview with R #37, he said he had problems with his right eye. R #37 said his right eye was blurry. R #37 said he went to the doctor for his eyes. D. On 01/25/24 at 4:42 PM, during an interview with SS, she said R #37 had a prescription for glasses. E. On 01/25/24 at 4:52 PM, during an interview, the MDS Nurse stated staff did not document in R #37's MDS that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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 a comprehensive person-centered care plan for 4 (R #3, R #30, R #43, and R #70) of 4 (R #3, R #30, R #43, and R #70) residents reviewed for comprehensive care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: A.On 01/25/24 at 1:45 PM, during an interview with the DON, she confirmed resident care plans should be person centered and should include the resident's activity preferences, so staff know what activities the residents liked to do. R #3 B. On 01/23/24 at 11:56 AM, during an interview with R#3, he stated he needed to have dental crowns (a type of restoration that covers and protects a damaged or decayed tooth). R #3 stated he had not had a dental visit for approximately five years. C. Record review of R #3'S Care Plan, dated 09/12/23, revealed the record…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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 revise the care plan for 2 (R #23 and R #37) of 4 (R #23, R #37, R #48, and R #63) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #23 A. On 01/23/24 at 12:28 PM, during an interview with R #23, she said she fell approximately three months ago. B. Record review of R #23's electronic medical record (EMR), no date, revealed R #23 fell in her bathroom on 10/01/23. C. Record review of R #23's care plan, initiated 03/27/23, revealed: 1. Intervention: R #23 had an actual fall with no injury, related to poor balance. 2. The care plan revision on 01/03/24 did not indicate the date the fall occurred or what changes in care the resident required after the fall. D. On 01/26/24 at 12:45 PM, during an interview with the DON, she confirmed R #23's care plan was not revised in a timely manner. R #37 E. Record review of R #37's care…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's 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 interview, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 2 (R #43 and R #70) of 3 (R #43, R #48, and R #70) residents reviewed for activities. If the facility does not ensure all residents receive an ongoing activity program and make in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are: A. On 01/25/24 at 1:45 PM, during an interview with the DON, she confirmed the following: 1. Activities has a one-to-one program where the staff meet one-to-one with residents. 2. Residents get in the one-to-one program depending on their activity needs. 3. Residents who cannot participate or do not like to participate in group activities should be included in the one-to-one program. R #43 B. On 01/25/24 at 9:57 AM, during an interview…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0685 — pattern
    Assist a resident in gaining access to vision and hearing services.
    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 ensure residents received proper treatment to maintain vision and hearing for 4 (R #3, R #37, R #51, and R #63) of 6 (R #3, R #12, R #37, R #48, R #51, and R #63) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot see or hear, which would compromise their quality of life. The findings are: R #3 A. Record review of R #3's quarterly MDS, dated [DATE], indicated R #3 needed glasses. B. Record review of R #3's care plan, dated [DATE], showed the resident had a history of glaucoma, and the facility would arrange appointments with the eye doctor. C. On [DATE] at 11:52 AM, during an interview with R #3, he stated he had not been to the eye doctor in three or four years. He said he felt his glasses were not as strong as they used to be, and he may require a new prescription. D. On [DATE] at 12:14 AM, during an interview, Social Services (SS) stated they did not provide…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 and interview, the facility failed to keep residents free from the potential for accidents for 1 (R #32) of 1 (R #32) residents reviewed for accidents, when they failed to ensure the mattress fit the bed. This deficient practice could likely result in injury. The findings are: B. On 01/23/24 at 11:09 AM, during an observation of R #32's room, the following was observed: 1. R #32's bed had a gap between the bariatric air mattress and the foot board. 2. Staff placed a pad between the mattress and the footboard. The pad was tall and did not extend to width of the mattress, with gaps on both sides of the pad. C. On 01/23/24 at 11:09 AM, during an interview, R #32 revealed the following: 1. The mattress and pad had been like that since before he was moved from his previous room to the skilled unit. 2. The mattress used to slide up and down in the bed so the staff put the pad there to prevent the mattress from sliding. D. Record review or R #32's medical record no date, revealed that R #32 was moved from another room to his current room on 11/02/23. E. On 01/24/24 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and failed to monitor the resident before and after dialysis treatment for 1 (R #30) of 1 (R #30) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the resident's condition or possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care. The findings are: A. Record review of R #30's admission record, no date, revealed R #30 had a diagnosis of end stage renal disease (ESRD; chronic irreversible kidney failure). B. Record review of R #30's physician orders revealed, order revision date 12/29/23, resident to have dialysis Monday, Wednesday, and Friday at 12:45 PM. C. Record review of R #30's Electronic Medical Record (EMR) revealed: 1. Dialysis Communication Record, dated 12/20/23 for dialysis time 12:00 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 demonstrated competency, were tested, or evaluated in skills and techniques necessary to care for residents' needs for 6 (CNA #31, CNA #32, CNA #33, LPN #34, LPN #35, LPN #36) of 6 (CNA #31, CNA #32, CNA #33, LPN #34, LPN #35, LPN #36) staff sampled for staff competency. This deficient practice could likely result in staff working who are not competent to give care to residents. The findings are: A. Record review of CNA #31's, CNA #32's, CNA #33's, LPN #34's, LPN #35's, LPN #36's personnel records revealed a On The Job Training/Competency Assessment form did not contain documentation to show the nursing staff demonstrated competency, were tested, or evaluated in skills and techniques necessary to care for residents' needs. B. On 01/24/24 at 3:30 PM, during an interview, the DON and ADON stated the On The Job Training and Competency Assessment form was the most current form the facility used to evaluate nursing staff competency. The DON and ADON stated the employees checked off the skills listed without 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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

    Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and acted on for 3 (R #11 and R #23, R #30) of 5 (R #11, R #23, R #30, R #48, and R #50) residents reviewed for pharmacy medication regimen review. This deficient practice could likely result in residents suffering from unnecessary adverse side effects. The findings are: R #11 A. Record review of the pharmacy recormendations for R #11, dated 10/31/23, revealed the following lab results could not be located on R #11 chart: Complete blood count (CBC), comprehensive metabolic panel (CMP), magnesum (Mg), thyroid stimulating hormone (TSH), free thyroxine 4 (FT4), lipid panel, Vitamin D level, folate level, and Vitamin B12 level. These labs were ordered by the physician on 09/29/23. B. Record review of R #11's Electronic Medical Record (EMR) revealed the record did not contain lab results for orders dated 09/29/23. C. On 01/10/24 at 12:56 PM, during an interview, the DON stated staff did not collect or draw the labs ordered for R #11 on 09/29/23. The DON stated 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record for 2 (R #48 and R #69) of 4 (R #11, R #30, R #48 and R #69) residents reviewed for unnecessary psychotropic medications. 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: R #48 A. Record review of R #48's admission record, no date, revealed an admission date of 09/03/21. B. Record review of R #48's Physician's orders revealed an order, dated 09/07/23, for aripiprazole (an antipsychotic medication used to treat bipolar disease) tablet, 2 mg. Give one tablet a day for bipolar disease. C. Record review of R #48's pharmacy review, Note to attending physician/prescriber, dated 11/29/23, revealed the following: 1. R #48 took aripiprazole, 2 mg, for bipolar disease since July 2023 2. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 properly store medications, when they failed to ensure medications were not expired in the Pyxis (medication management software and medication dispensing machine). This deficient practice could affect all 73 residents in the facility. Residents were identified by the resident matrix provided by the Administrator on 01/15/24. This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects. The findings are: A. On 01/25/24 at 11:15 AM, an observation of the Pyxis in the Medication Storage Room revealed the following medications were expired: 1. Singulair (medication used to treat allergies and prevent asthma attacks), 10 mg, expired 06/28/23. 2. Allopurinol (medication used to treat gout and kidney stones), 100 mg, expired 05/10/23. 3. Finasteride (medication used to treat enlarged prostate), 5 mg, expired 06/08/23. 4. Atenolol (medication used to treat high blood pressure and chest pain, It can also reduce the risk of death after a heart attack),…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to obtain laboratory testing for 1 (R #23) of 1 (R #23) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered this could delay treatment of potential medical issues and could cause unnecessary harm to the resident. The findings are: A. Record review of R #23's progress notes revealed: 1. Nursing progress note, dated 10/30/23, stated R #23 complained of red urine. Staff contacted the on-call provider, and the resident was to follow-up with their primary physician. 2. Provider progress note, dated 11/01/23, for chief complaint of hematuria (blood in urine). Order urinalysis with culture and sensitivity and other labs. B. Record review of R #23's Physician's orders revealed an order, dated 11/01/23, complete blood count (CBC; blood test that measures many different parts and features of your blood) with differential, comprehensive metabolic panel (CMP; blood sample test that measures 14 different substances in your blood), thyroid stimulating hormone (TSH), hemoglobin A1C…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments for 1 resident (R #3) of 1 resident (R#3) resident reviewed for dental services. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R #3 A. On 01/23/24 at 11:56 AM, during an interview with R#3, he stated he needed to have dental crowns (a type of restoration that covers and protects a damaged or decayed tooth). R #3 stated he had not had a dental visit for approximately five years . B. On 01/25/24 at 1:30 PM, during an interview with the Social Services Director (SSD), She stated R #3 has not had a dental exam since 2012.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 the medical records contained documentation each resident received or was offered pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) and influenza (an acute respiratory infection caused by influenza viruses) immunizations for 2 (R #43 and R #70) of 5 (R #11, R #19, R #30, R #43, and R #70) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: A. On 01/25/24 at 5:59 PM, during an interview with the DON, she stated the following: 1. The Infection Preventionist (IP) nurse was expected to offer and administer influenza and pneumococcal vaccinations to all residents. 2. The facility staff have a 48 hour meeting where the IP nurse was expected to meet with new residents and/or their representatives to discuss their vaccination status. 3. All vaccinations should be documented in the resident's Electronic Medical Record (EMR). 4. All…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 the residents' medical record contained documentation each resident received or was offered covid-19 (an acute respiratory infection caused by the SARS-CoV-2 virus) immunization for 1 (R #43) of 5 (R #11, R #19, R #30, R #43, and R #70) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: A. On 01/25/24 at 5:59 PM, during an interview with the DON, she stated the following: 1. The Infection Preventionist (IP) nurse was expected to offer and administer the covid-19 vaccinations to all residents. 2. The facility staff have a 48 hour meeting after the resident is admitted , where the IP nurse was expected to meet with new residents and/or their representatives to discuss their vaccination status. 3. All vaccinations should be documented in the resident's Electronic Medical Record (EMR). 4. All refusals for vaccinations should be documented in the resident's EMR. B.…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-11-20 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to post nurse staffing data on a daily basis that included the following: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses. iii. Certified nurse aides. iv. Resident census. This deficient practice could likely result in resident not knowing the staf working. The findings are: A. On 11/16/2024 at 1:15 pm, during an observation there was no nurse staff posting for the day at the main nurses station. Observation of the nurses station in the 100 hall, staff posting available at nurses station was dated 09/26/2024. B. On 11/16/2024 at 1:19 pm, during an interview, LVN (licensed vocational nurse) # 1 she attempted to find the posting display frame located at the nurses station and it was empty. She stated staff did not post the nurse staffing information for that day at the main hall nurses station in the display as they should…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$17,215 in federal fines across 1 penalty.

  • $17,215 — penalty dated 2026-01-30

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 OPCO SKILLED MANAGEMENT — 66 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 →

RatingThis homeChain avg
Overall 5 of 52.3+2.7 vs chain
Health inspection 4 of 52.2+1.8 vs chain
Staffing 3 of 51.7+1.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 65 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Bluebird Wellness And RehabilitationSaint Louis, MO 1 of 5Brentwood Place ThreeDallas, TX 1 of 5Broadway Nursing & RehabilitationSan Antonio, TX 1 of 5Cameron Nursing CenterCameron, MO 1 of 5Carmel Hills Wellness & RehabilitationIndependence, MO 1 of 5Casa Arena Healthcare LLCAlamogordo, NM 1 of 5Casa Maria HealthcareRoswell, NM 1 of 5Forest Park Nursing & RehabilitationDallas, TX 1 of 5Fort Worth Wellness & RehabilitationFort Worth, TX 1 of 5Glenview Wellness & RehabilitationNorth Richland Hills, TX 1 of 5Highland Pines Nursing HomeLongview, TX 1 of 5Ivy Creek Wellness & RehabilitationWaco, TX 1 of 5Las Cruces Village Nursing & Rehabilitation LLCLas Cruces, NM 1 of 5Magnolia Wellness CenterSaint Louis, MO 1 of 5Maple Grove Wellness & RehabilitationFenton, MO 1 of 5Mineola Gardens Wellness & RehabilitationMineola, TX 1 of 5Pine Grove ManorSaint Louis, MO 1 of 5Rehab Of Kansas City SouthKansas City, MO 1 of 5The Hillcrest Of North DallasDallas, TX 1 of 5West Side Campus Of CareWhite Settlement, TX 1 of 5Willow Ridge Wellness & RehabilitationFort Worth, TX 1 of 5Willowcreek Wellness & RehabilitationFlorissant, MO 2 of 5Arbor Lake Nursing & Rehabilitation, LLCFort Worth, TX 2 of 5Aztec HealthcareAztec, NM 2 of 5Betty Dare Wellness & Rehabilitation LLCAlamogordo, NM 2 of 5Blue Springs Wellness & RehabilitationBlue Springs, MO 2 of 5Cypress Springs Wellness & RehabilitationMount Vernon, TX 2 of 5Fiesta Park Wellness & RehabilitationAlbuquerque, NM 2 of 5Hilltop At Blue River, TheKansas City, MO 2 of 5La Vida Buena HealthcareLas Vegas, NM 2 of 5Los Alamos Wellness & RehabilitationLos Alamos, NM 2 of 5McGregor Wellness & RehabilitationMc Gregor, TX 2 of 5Monarch Springs Wellness & RehabilitationUniversity City, MO 2 of 5Northrise Wellness & RehabilitationLas Cruces, NM 2 of 5Prescott Valley Nursing & RehabilitationPrescott Valley, AZ 2 of 5Prescott Village Nursing & RehabilitationPrescott, AZ 2 of 5Rehabilitation Center Of Independence, TheIndependence, MO 2 of 5San Antonio Wellness & RehabilitationSan Antonio, TX 2 of 5Skyline Nursing CenterDallas, TX 2 of 5Sunny Springs Nursing & RehabSulphur Springs, TX

Showing 40 of 65; lowest-rated first.

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 / managerTypeRoleSince
1701 DESERT SPRINGS OPCO HOLDINGS, LLCOrganizationDIRECT OWNERSHIP INTERESTsince 05/07/2019
EMBUDO TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 05/07/2019
OXFORD SQUARE LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/07/2019
RIMPAU HOLDINGS TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 05/07/2019
SASEM INVESTMENTS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/07/2019
WELLINGTON HC PARTNERS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/07/2019
GARETZ, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/16/2020
DAVIDOVICH, NIVIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
GURWITZ, SOLOMONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
HAGINS, ELIZABETHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
KAPLAN, ESTHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
KAPLAN, MORDECHAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
MINDLE, ADAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
STERNSHEIN, JENNIFERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
UNGER, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
ZIMMERMAN, CAROLINEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/24/2025
1701 N TURNER STREET NM, LLCOrganizationADP OF THE SNFsince 05/07/2019
ADIRONDACK TRUSTOrganizationADP OF THE SNFsince 05/07/2019
BIGHORN TRUSTOrganizationADP OF THE SNFsince 05/07/2019
BLUE RIDGE HC TRUSTOrganizationADP OF THE SNFsince 05/07/2019
CONTINUUM REHAB GROUP LLCOrganizationADP OF THE SNFsince 05/07/2019
FTNM PROPCO HOLDINGS, LLCOrganizationADP OF THE SNFsince 05/07/2019
GIBRALTAR TRUSTOrganizationADP OF THE SNFsince 05/07/2019
HANSEN HUNTER LLCOrganizationADP OF THE SNFsince 04/01/2024
OPCO CA SKILLED MGMT INC.OrganizationADP OF THE SNFsince 05/07/2019
OPCO NM SKILLED MGMT, LLCOrganizationADP OF THE SNFsince 05/07/2019
THE WRIGHT GROUP CONSULTING, LLCOrganizationADP OF THE SNFsince 04/01/2024
JONES, AMYIndividualADP OF THE SNFsince 06/15/2024
STOLARCZYK, LISAIndividualADP OF THE SNFsince 02/01/2024

CMS files one row per role, so the 30 rows in the source record cover these 29 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.

17 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.

$10.3M
Net patient revenuemost recent cost report
-15.5%
Operating marginrevenue minus expenses
$3.1M
Related-party expense26% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 11%Other / private 11%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 26% 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 2024. 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

$438per resident / day
operating cost
$13,314per month
≈ monthly operating cost
$379per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

Paying with Medicaid

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.

Typical monthly cost in New Mexico
$9,125/mo
Nursing home (semi-private)
$10,633/mo
Nursing home (private)
$5,950/mo
Assisted living

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 325129. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, 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.

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