White Sands Healthcare
5715 North Lovington Highway, Hobbs, NM 88240 · For profit - Corporation · 118 certified beds · (575) 392-6845 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0609) — most recent Nov 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 2 serious findings 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 (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,528 in federal fines (most recent 2025-11-18)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 29% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.3% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 0.9% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.3% | 2.0% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.3% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.9% | 11.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 31.7% | 14.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 98.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.3% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.3% | 14.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.5% | 86.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.2% | 22.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 31.1% | 15.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.44 | 1.65 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.53 | 2.81 | 1.80 | worse |
‡ 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.
38.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.7% 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 30 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.1%CMS range 28.1–47.7 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.1%CMS range 9.4–18.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.3%CMS range 5.1–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 118 beds and averages 106.4 residents a day — about 90% occupied, or roughly 12 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.78 hrs/resident/day on weekends vs 3.32 on weekdays — 16% thinner on weekends. RN hours go from 0.62 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
36 citations, most serious first. The 13 most serious are shown; the remaining 23 are one tap away and print in full.
- Immediate jeopardy · L2025-11-18 · tag F0600 — failed to protect residents from abuse and neglect — widespreadProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 keep a resident free from abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse when Nurse Aide in Training (NAIT) #2 was verbally and physically abusive to R #4 when providing care. This deficient practice likely resulted (based upon the reasonable person standard) in R #4 experiencing emotional distress and trauma. The findings are:A. Record review of R #4's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Anxiety (feelings of fear or apprehension) disorder,3. Legal blindness (inability to see),4. Cerebrovascular disease (refers to a group of disorders affecting blood flow to the brain, leading to conditions such as stroke, aneurysms, and vascular malformations).B. Record review of R #4's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed…
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.
- Immediate jeopardy · L2025-11-18 · tag F0609 — failed to report abuse allegations — widespreadTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to report an allegation of abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse, when staff waited 7 days to report witnessed staff to resident abuse. If the staff fail to report allegations of abuse to the facility administration, then corrective measured may not be acted on and the facility would be unable to assure residents are free from abuse. The findings are:Cross reference findings for F600A. Record review of R #4's complaint report dated 08/29/25 revealed on 08/22/25 an alleged incident of abuse had occurred as follows:- Certified Nurse Aide (CNA) #1 had witnessed NAIT (Nurse Aide in Training) #2 cover R #4's mouth with hand, tap his mouth with her hand, and told R #4 to shut up.-The incident was reported to the management team on 08/29/25. NAIT #2 continued to work until management was notified of incident. NAIT #2 remained in the unit and the residents in the unit were at risk for further abuse by the accused NAIT #2.B. Record review of facility timesheets identified that NAIT #1 worked at the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-07-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
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 #1) of 1 (R #1) resident reviewed for falls, when the facility failed to ensure staff used a mechanical lift as required.This deficient practice resulted in R #1 falling and sustaining a Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) was identified on (Computed Tomography; a medical imaging procedure that uses x-rays to create detailed cross-sectional images of the body) CT that required treatment at a hospital for higher level of care.A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and currently has the following diagnoses:1. Type 2 Diabetes.2. Alzheimer's (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).3. Anxiety (feeling of unease, worry, or nervousness).4. Repeated Falls.5. Hypertension (A condition in which the force of the blood against the arty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 interviews, the facility failed to obtain consent from a resident representatives prior to giving a significant haircut to a resident living on the memory care unit for 1 (R #2) of 4 (R #1, R #2, R #3 and R #4) residents reviewed. This deficient practice could likely result in residents feeling a loss of humanity and dignity. The findings are: A. Record review of the facility's admission Agreement, dated 12/2023, revealed the facility may share medical information with family to identify a surrogate decision maker when an individual was incapacitated and unable to give or receive information. B. Record review of R #2's admission Record revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: 1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), with severe behavioral disturbances,2. History of traumatic brain injury (TBI; head or neck injury). C. Record review of 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.
- Potential for harm · E2026-03-12 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 3 (R #2, R #6, and R #9) of 5 (R #2, R #5, R #6, R #9, and R #31) residents reviewed for unnecessary medications, when staff failed to:1. Ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record for R #2.2. Ensure as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #9.These deficient practices could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #2 A. Record review of R #2's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: 1. Unspecified mood disorder (mental health condition that is characterized by a persistent feeling of sadness, hopelessness, and loss…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-12 · tag F0641 — patternEnsure 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 2 (R #9 and R #31) of 4 (R #5, R #9, R #11, and R #31) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: R #9A. Record review of R #31's physician's orders revealed an order dated 08/13/25 for Aspirin enteric coating (EC; Specialized barrier to oral medications to prevent dissolution in the acidic stomach) oral tablet eighty-one milligrams (mg) to be given by mouth in the morning for analgesic (pain medication).B. Record review of R #31's quarterly MDS assessment dated [DATE] revealed R #9 does not receive scheduled pain medications.C. On 3/12/25 at 10:03 am, during an interview with MDS Coordinator (MDS), she confirmed R #9 's quarterly MDS is inaccurate because she does take Aspirin for pain regularly.R #31D. 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.
- Potential for harm · E2026-03-12 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 2 (R #114 and R #115) of 4 (R #5, R #9, R #114 and R #115) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #114 A. Record review of R #114 admission Record revealed he was admitted to 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. Hyperlipidemia (a condition in which there are high levels of fat particles in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure food was served under sanitary conditions when staff failed to follow safe food handling practices when they:1. Touched the rims of cups while serving residents' drinks.2. Failed to sanitize their hands after touching dirty (items that may be soiled or contaminated) and serving residents' meals. These deficient practices are likely to affect all 111 residents listed on the resident census list provided by the Administrator on 03/08/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly.The findings are:A. On 03/08/26 at 12:16 pm, an observation of the lunch dining services revealed the following:1. Licensed Vocational Nurse (LVN) #3 assisted R #82 into the dining area by holding her hand and walking with her. LVN #3 then served R #92 her lunch meal without washing or sanitizing her hands. 2. LVN #3 served R #47's meal and touched the cup by the top of the rim when placing it on the table.3. LVN #3 served R #36's meal and touched the cup 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.
- Potential for harm · Dcited before2026-03-12 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 PASARR (Preadmission Screening and Resident Review) Level I Identification Screen was accurate for 2 (R #68 and R #98) of 5 (R #1, R #2, R #10, R #68, and R #98) residents reviewed for PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being. The findings are:R #68 A. Record review of R #68's admission Record revealed R #68 was admitted to the facility on [DATE] with the following diagnoses: 1. Metabolic encephalopathy (is a change in how your brain works due to an underlying condition), 2. Generalized anxiety disorder (GAD; is a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), 3. Hemiplegia (paralysis of the arm, leg, and trunk on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
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 2 (R #8 and R #59) of 8 (R #1, R #2, R #4, R #6, R #7, R #8, R #10, and R #59) residents reviewed when staff failed to: -Revise R #8's care plan using his name, not another resident's name.-Revise R #59's care plan to indicate a fall mat was in use.These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated accurately. The findings are:R #8 A. Record review of R #8's care plan, dated 02/17/26 revealed the following: 1. Focus areas for enhanced barrier precautions revealed Nursing to educate [Name of other resident] and/or family members on the evidence-based practice justification for utilizing enhanced barrier precautions when providing direct care. 2. Focus area for vision revealed the use of another resident's name in the interventions. B. On 03/12/26 at 10:30 am, during an interview with the Director of Nursing (DON) she confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #9) of 5 (R #2, R #4, R #8, R #9, and R #31) residents reviewed for respiratory care when the facility failed to ensure medical orders indicated when to administer R #9's oxygen. 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:A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE] with the following diagnoses:1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Anxiety (feelings of fear or apprehension),3. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),4. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0700 — isolatedTry 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to obtain appropriate physician orders prior to installation of bed rails for 1 (R #5) of 3 (R #5, R #11, and R #31) residents reviewed for bedrails. This deficient practice could result in the physician, staff, and residents not knowing the needs, risks and benefits of bed rails. The findings are:A. Record review of R #5's admission Record revealed R #5 was admitted to the facility on [DATE].B. Record review of R #5's physician orders revealed no order for the use of bedrails.C. On 03/09/26 at 2:12 pm, a random interview and observation of R #5's room revealed quarter size bedrail on the upper left side of the bed. R #5, he confirmed he uses the side rail for mobility and repositioning himself. D. On 03/12/26 at 10:27 am, during an interview with the Director of Nursing (DON), she confirmed the R #5 does not have physician orders for use of bedrails and should prior to installation of the bedrail.
- Potential for harm · D2026-03-12 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following:- Facility name.-The current date.-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.1. Registered nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census.The deficient practice has the potential to affect all 111 residents as identified by the census provided by the Administrator (ADM) on 03/08/26 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 03/09/26 at 10:01 am a random observation of the facility revealed the facility's staff data posting was dated 03/08/26.B. On 03/09/26 at 10:07 am, during an interview with the Registered Nurse (RN) #1, she confirmed the staff data posting was dated 03/08/26 and had not been updated. She confirmed it should be updated daily but was not.
Show the remaining 23 citations
- Potential for harm · Dcited before2026-03-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all medications were not expired in the medication storage room. This deficient practice has the potential to affect any resident requiring emergency opioid overdose reversal by providing a medication with potentially reduced efficacy. The findings include:A. On [DATE] at 11:17 am, during an observation of the medication storage room, a vial of Naloxone 0.4 mg/ml, one milliliter (ml) as needed (PRN) injection was located in the medication refrigerator. The manufacturer's expiration date printed on the vial was 12/2025.B. On [DATE] at 11:30 am, during an interview with the Director of Nursing (DON), she confirmed the Naloxone vial was expired and stated it should have been removed from the refrigerator and placed in the designated pharmacy return or destruction area.C. A review of the facility's Medication Storage and Expiration pharmacy policy and procedure manual revised in 09/2010, revealed staff are required to audit medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 maintain proper infection prevention measures for 2 (R #5 and R #115) of 4 (R #4, R #5, R #10, and R #115) residents reviewed by not:1. Ensuring Personal Protective Equipment (PPE) was properly used,2. Ensuring Enhanced Barrier Protection (EBP) signage is visibly posted and PPE is available near resident's room when precautions are in place.These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are: A. On 03/09/26 at 11: 42 am, during a random observation of the 300 hall, Certified Nurse Aide (CNA) #2 was observed exiting room [ROOM NUMBER] wearing a gown and gloves. B. On 03/09/26 at 11:43 am during an interview with CNA #2, she confirmed she should not have exited the room wearing her PPE and is required to take off her PPE prior to exiting the room but did not. C. On 03/09/26 at 1:37 pm during an interview with the Infection Prevention Coordinator (IPC). She stated that her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-11-18 · tag F0728 — failed to protect against nurse-aide misconduct — widespreadEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure a Nurse Aide in Training (NAIT) completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 108 residents residing at the facility by allowing untrained staff to provide direct care to residents. The findings are:A. Record review of NAIT #1's personnel record reviewed the following:1. NAIT #2's hire date was 11/15/24.2. NAIT #2 became a Nurse Aid in training on 02/16/25.3. NAIT #2's date of Certified Nurse Aide certification was 8/26/25.B. Record review of NAIT #2's timesheet revealed NAIT #2 worked a total of 99 shifts between 02/16/25 and 08/26/25.C. On 10/14/25 at 5:29 pm, during an interview with the Human Resources Director (HRD), she confirmed NAIT #2 received her certification late and continued to work shifts during that time. She stated her expectation is for all nurse aids to become certified within four months.
- Potential for harm · E2025-05-23 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 were free of any significant medication errors for 1 (R #1) of 1 (R #1) resident reviewed for medication administration when staff failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication. The findings are: A. Record review of R #1's Physician's orders revealed the following: 1. Metoprolol succinate (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) ER (extended release), extended release 24-hour, started on 11/24/23. Give 50 MG (milligram; dose of medication) by mouth one time a day for hypertension (high blood pressure). Hold if SBP (Systolic blood pressure; the top number in a blood pressure reading) is less than 120, DBP (Diastolic blood pressure; the bottom number in a blood pressure reading) is less than 80, HR (Heart rate; number of times the heart beats in a min) is less…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-23 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 27 people residing in rooms on the 200 hall by allowing unauthorized people access to their medical supplies and personal health information. The findings are: A. On 05/22/25 at 10:15 am, a random observation of the facility revealed the treatment cart located in the 200 hall was unlocked, and the facility employees were not in the area. B. On 05/22/25 at 10:15 am, during an interview with Registered Nurse (RN) #1, she confirmed the treatment cart was unlocked and she locked the cart. RN #1 stated the treatment cart should be locked and secured while not in use. C. On 05/23/25 at 10:25 am, during an interview with the Director of Nursing (DON), she confirmed that all treatment carts should be locked while not in use.
- Potential for harm · E2025-05-23 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to safeguard resident's personal health information by leaving a list of residents with their associated wound care orders in plain view. This deficient practice had the potential to affect all 27 people residing in the rooms on the 200 hall by allowing unauthorized people access to their personal health information. The findings are: A. On 05/22/25 at 10:15 am, a random observation of the facility revealed a paper document with names of the residents and their wound care orders sitting face up on top of the treatment cart. B. On 05/23/25 at 10:25 am, during an interview with the Director of Nursing (DON), she confirmed that all personal health information should be safeguarded and should never be left in view of people that are not authorized to see it.
- Potential for harm · F2025-01-13 · tag F0575 — widespreadPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and observation the facility failed to ensure residents received information on how to contact the State Survey Agency to file a complaint. This deficient practice could likely affect all 110 residents residing in the facility as identified on the census provided by the Administrator (ADM) on 01/05/25. The findings are: A. On 01/05/25 at 12:15 pm during a random observation of the facility, signs or posters regarding filing a complaint with the state survey agency were not visible throughout the facility. B. On 01/07/25 at 10:58 am during an interview with the Resident Council (RC; R #9, R #28, R #29, R #36, R #46, R #73, R #77, R #86, and R #97), they stated they were unaware they could contact the State Survey Agency to file a complaint. C. On 01/08/25 at 12:39 pm during an interview and random observation of the facility with the Administrator, one sign regarding contacting the State Survey Agency to file a complaint hung on the front entrance door and faced outside the building. Further observation revealed there were not any signs or posters…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide a clean and homelike environment when staff did not clean vomit off the floor in the dining area of the memory care unit. This deficient practice could likely affect all 21 residents residing in the memory care unit as identified by the census provided by the Administrator on 01/05/25. Failure to provide a clean and homelike environment is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. The findings are: A. On 01/06/25 at 9:10 am, a random observation of the memory care unit revealed vomit on the floor in the dining area by the door leading outside. B. On 01/06/25 at 9:13 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated the vomit was on the floor since breakfast. She stated she informed housekeeping staff, and they told her someone would clean it later. C. On 01/13/25 at 2:07 pm, during an interview with the Director of Nursing, she stated nursing staff should clean up bodily fluids such as vomit. She stated her expectation would be for nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-13 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
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 Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 5 (R #23, R #25, R #95, R #98, R #104) of 6 (R #17, R #23, R #25, R # 95, R #98, R #104) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need. The findings are: R #23 A. Record review of R #23's face sheet revealed R #23 was admitted into the facility on [DATE] with the following diagnoses: 1. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 2. Anxiety disorder (feelings of fear or apprehension), 3. Schizoaffective disorder (a mental condition that causes both psychosis and mood problems)-bipolar type (a disorder associated with episodes of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-13 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 2 (R#1 and #26) of 8 (R #1, R #23, R #25, R #26, R #55, R #65, R #95, and R #98) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #26 A. Record review of R #26's face sheet revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Idiopathic chronic gout (a type of arthritis that causes intense pain, swelling, redness and tenderness of an affected joint). 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), recurrent, mild, 3. Blindness, left eye, 4. Heart failure, unspecified, 5. Chronic kidney disease, severe (CKD; impaired kidney function.) B. Record review of R #26'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.
- Potential for harm · Ecited before2025-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 2 (R #17 and R #104) of 3 (R #17, R #70, and R #104) residents reviewed for respiratory care when staff failed to change the oxygen concentrator (a medical device that provides extra oxygen) tubing. If the facility fails to provide new, clean tubing for oxygen concentrators then residents are at risk of becoming ill. The findings are: R #17 A. Record review of R #17's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including: 1. Unspecified dementia, severe with psychotic disturbance, anxiety, and behavioral disturbance, 2. Seizures, 3. Chronic kidney disease (kidneys are damaged and can't filter blood the way they should), 4. Other bipolar disorder (mental health condition that causes extreme mood swings), 5. Dependence on supplemental oxygen (treatment that provides extra oxygen to people who have trouble breathing or lung…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-13 · tag F0700 — patternTry 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) in bed rails for 6 (R #23, R #25, R #55, R #65, R # 95, and R # 98) of 8 (R #21, R #23, R #25, R #55, R #65, R #77, R #95, and R #98) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R #23 A. Record review of R #23's admission record revealed R #23 was admitted to the facility on [DATE]. B. On 01/09/25 at 10:55 AM, during an observation, R #23's bed had two bilateral (on both sides) quarter side rails (horizontal metal or plastic bars that extend about a quarter of the length of a bed) in place. C. Record review of R #23's physician orders reviewed, dated 08/09/24 through 01/09/24, revealed the resident did not have a physician order for bed rails. D. Record review of R #23's care plan, dated 11/17/24 and revised date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-13 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less when staff administered medications without wearing gloves or using a medication cup for 1 (R# 30) of 1 (R# 30) residents reviewed during medication administration. This resulted in a medication error rate of 15.63%. If the staff members do not wear gloves or use a medication cup when administering medications, then residents are likely to become ill due to cross-contamination. The findings are: A. On 01/10/25 at 8:30 am during an observation of medication administration for R# 30, RN #1 entered the resident's room and asked if he was ready for his medications. R# 30 stated he was ready. RN #1 cleaned his hands with alcohol-based hand sanitizer (ABHS; hand cleanser that has alcohol in it to kill bad germs). He pulled out the over the counter (OTC) medications (medications that do not need a prescription from the physician and can be bought in most stores) from the medication cart in the hallway. RN #1 used his bare hands to open the first bottle of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to promote care with dignity and respect for 2 (R #52 and R #9) of 2 (R #52 and R #9) residents reviewed for rights when they: 1. Provided a medical assessment in the dining area during mealtime. 2. Interrupted a resident during mealtime to prepare her to take medications. This deficient practice could result in residents feeling as if they were unimportant and not having privacy. The findings are: R #52 E. Record review of R #52's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Type 2 diabetes mellitus without complications, 2. Unspecified protein-calorie malnutrition, 3. Unspecified dementia, severe with anxiety and behavioral disturbance, 4. Cardiomegaly (enlarged heart). F. Record review of R #52's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) revealed a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 2,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions when they failed to remove an unlabeled and undated pitcher of white liquid from the television area of the memory care unit. This deficient practice could likely affect all 21 residents residing in the memory care unit as identified on the census provided by the Administrator (ADM) on 01/05/25. The findings are: A. On 01/06/25 at 10:10 am, a random observation of the memory care unit revealed a pitcher of white liquid that was not labeled or dated. Further observation revealed the pitcher sat on a tray in the television room of the memory care unit, and there were several residents present including R #72 and R #61. B. On 01/06/24 at 10:13 am, during an interview, Nurse Aide in Training (NAIT) #1 she stated the pitcher of white liquid was not labeled or dated and should not have been left on the tray where residents had access to it. She stated the pitcher was probably milk from breakfast. C. Record review of the facility's mealtimes revealed that breakfast was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-01 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to properly inform 1 (R #92) of 1 (R #92) resident of treatment decisions by failing to utilize interpreter line (service used for communication) or a communication board to communicate with resident in a language the resident could understand. If the facility is not able to communicate with residents then residents are not likely to get their needs met. The findings are: A. Record review of R #92's face sheet revealed R #92 was admitted into the facility on [DATE]. B. Record review of R #92's care plan, dated 02/22/24, revealed the following: - Focus: R #92 had a communication problem related to only spoke [name of language that is not English]. - Interventions: R #92 was able to communicate by: translator. Use effective strategies touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, one to one, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-01 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet professional standards of care and failed to monitor oxygen (O2) equipment for 3 (R #'s 24, 41, and 69) of 3 (R #'s 24, 41, and 69) residents reviewed for O2 administration when staff failed to: 1. Label, date, and change oxygen (O2; labeling and date as to when the O2 was replaced with new tubing) for R #'s 24 and 41. 2. Administer O2 per physician's orders and have O2 equipment available in the room for R #69. If the facility is not changing and labeling oxygen tubing or providing O2 per physician orders, then residents are likely to not receive the therapeutic benefits and care needed. The findings are: The findings are: A. Record review of the facility oxygen administration policy, dated 06/20, revealed all oxygen tubing used to deliver oxygen should be changed weekly, when visibly soiled, or as indicated by state regulation. Findings for R #24: B. Record review of R #24's face sheet revealed R #24 was admitted into the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update the medical chart for 1 (R #32) of 1 (R #32) residents reviewed for advanced directives when they failed to update the resident's code status. This deficient practice is likely to result in residents not having their wishes honored if a life threatening event occurred. The findings are: A. Record review of R #32's Physicians orders, dated [DATE], indicated staff should attempt resuscitation (CPR). B. Record Review of R #32's Medical Orders for Scope of Treatment (MOST; an advanced directive), dated [DATE], indicated the resident's advanced directive was do not resuscitate (DNR). C. Record Review of the R #32 Care Plan, dated [DATE], indicated the resident's advanced directive was DNR. D. On [DATE] at 12:31 PM during an interview with the Director of Nursing (DON), she stated R #32's MOST and the care plan did not match with the Physician's orders, and they should match. The DON further stated the resident's most recent MOST form was not in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
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 2 (R #41 and #32) of 2 (R #41 and #32) residents reviewed when staff failed to: 1. Update the care plan to include oxygen (O2) use. 2. Update the care plan to match the physician's orders. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: Resident #41 A. Record review of R #41's face sheet revealed R #41 was admitted into the facility on [DATE]. B. Record review of R #41's physician orders, dated [DATE], revealed an order for oxygen (O2) at 2 to 3 liters per minute (lpm) per nasal cannula (a type of O2 tubing) via concentrator or tank as needed for shortness of breath and wheezing. Keep oxygen saturations (amount of oxygen in the blood) at 92 or above. C. On [DATE] at 10:39 am during an observation, R #41 used O2. D. On [DATE] at 10:46 am during an interview with Certified Nursing Assistant (CNA) #2, she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide food that accommodated resident preferences for 1 (R #41) of 1 (R #41) residents observed for food preferences. This deficient practice is likely to result in weight loss due to the resident not eating or an allergic reaction to the food being served to the resident. A. Record review of R #41's physician order dated 02/26/24 revealed an order for regular diet, pureed with ground meat texture and mildly thick consistency. B. Record review of R #41's dinner meal ticket, dated 02/06/24, revealed staff to serve the resident one cup of pureed pork posole, pureed soft cooked vegetable, pureed broccoli, pureed frosted gelatin poke cake, and pureed tortilla. C. On 02/26/24 at 5:13 pm during a dinner observation, staff served R #41 pureed broccoli, pureed tortilla, pureed frosted gelatin poke cake, and regular consistency posole with whole pieces of meat in the posole. R #41 was eating the regular posole when staff took the regular posole away from R #41 to bring him pureed posole. D. On 02/26/24 at 5:37 pm…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to provide a therapeutic diet as ordered by a Physician for 1 (R #41) of 1 (R #41) residents reviewed during random dining observations. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake and may be at risk for choking. The findings are: A. Record review of R #41's physician order dated 02/26/24 revealed an order for regular diet, pureed with ground meat texture and mildly thick consistency. B. Record review of R #41's dinner meal ticket, dated 02/06/24, revealed staff to serve the resident one cup of pureed pork posole, pureed soft cooked vegetable, pureed broccoli, pureed frosted gelatin poke cake, and pureed tortilla. C. On 02/26/24 at 5:13 pm during a dinner observation, staff served R #41 pureed broccoli, pureed tortilla, pureed frosted gelatin poke cake, and regular consistency posole with whole pieces of meat in the posole. R #41 ate the regular posole. D. On 02/26/24 at 5:31 pm during an…
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.
- No harm found · Ccited before2025-01-13 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1. Ensure medications and other medical supplies were not expired. 2. Ensure medications for 1 (R #88) of 1 (R #88) residents were destroyed after completion of therapy. This deficient practice has the potential to affect all 110 residents identified on the facility census list provided by the Administrator on [DATE]. The use of expired medication is likely to cause residents to receive medications which are less effective due to a breakdown in chemical makeup, leading to less-than-optimal benefit from medications. Continuing to leave discharged /completed medications in the medication storage room is likely to cause residents to receive a medication that is not theirs. The findings are: Expired Medication A. On [DATE] at 8:20 am, during observation and interview with Assistant Director of Nursing (ADON) in the medication room located on the Skilled Care Unit, an Ultrasound Gel, 8.5 ounce (oz), expired on [DATE] sat on top of the refrigerator by 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.
- No harm found · C2024-03-01 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to have the most recent survey results in a place that was readily accessible (a place, such as a lobby or other area frequented by most residents, visitors, or other individuals where individuals wishing to examine survey results do not have to ask to see them) for all 105 residents residing in the facility. If residents are unable to locate the latest survey results conducted by State Surveyors, residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 02/27/24 at 11:02 am during a resident council meeting with R #11, 13, 18, 44, 45, 95, the residents stated they did not know where to locate the State Survey results, and they were not aware the survey results were available for review. B. On 02/27/24 at 5:59 pm during random observation of facility common areas, the State Survey results were not available for the residents to review. Further observation revealed there was not any signs as to where the State Survey binder was located. C. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$21,528 in federal fines across 2 penalties.
- $13,250 — penalty dated 2025-11-18
- $8,278 — penalty dated 2025-07-16
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.3 | -0.3 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 2 of 5 | 1.7 | +0.3 vs chain |
| Quality measures | 3 of 5 | 4.3 | -1.3 vs chain |
The other 65 homes this chain runs (chain average 2.3★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| 5715 WHITE SANDS OPCO HOLDINGS, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 05/07/2019 |
| OXFORD SQUARE LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 05/07/2019 |
| PINTADA TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 05/07/2019 |
| RIMPAU HOLDINGS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 05/07/2019 |
| SASEM INVESTMENTS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 05/07/2019 |
| WELLINGTON HC PARTNERS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 05/07/2019 |
| GARETZ, DAVID | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 12/16/2020 |
| STOLARCZYK, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2024 |
| ZEMMIN, KRISTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/23/2025 |
| DAVIDOVICH, NIV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| GURWITZ, SOLOMON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| HAGINS, ELIZABETH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| KAPLAN, ESTHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| KAPLAN, MORDECHAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| MINDLE, ADAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| STERNSHEIN, JENNIFER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| UNGER, JEFFREY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| ZIMMERMAN, CAROLINE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/25/2025 |
| 5715 N LOVINGTON HWY NM, LLC | Organization | ADP OF THE SNF | since 05/07/2019 |
| ADIRONDACK TRUST | Organization | ADP OF THE SNF | since 05/07/2019 |
| BIGHORN TRUST | Organization | ADP OF THE SNF | since 05/07/2019 |
| BLUE RIDGE HC TRUST | Organization | ADP OF THE SNF | since 05/07/2019 |
| CONTINUUM REHAB GROUP, LLC | Organization | ADP OF THE SNF | since 05/07/2019 |
| FTNM PROPCO HOLDINGS, LLC | Organization | ADP OF THE SNF | since 05/07/2019 |
| GIBRALTAR TRUST | Organization | ADP OF THE SNF | since 05/01/2019 |
| HANSEN HUNTER LLC | Organization | ADP OF THE SNF | since 07/25/2025 |
| OPCO CA SKILLED MGMT INC. | Organization | ADP OF THE SNF | since 05/07/2019 |
| OPCO NM SKILLED MGMT, LLC | Organization | ADP OF THE SNF | since 05/07/2019 |
| THE WRIGHT GROUP CONSULTING, LLC | Organization | ADP OF THE SNF | since 04/01/2024 |
CMS files one row per role, so the 32 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.
About 89% 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 $4.5M paid to related parties — landlords or management companies under common ownership — equal to about 29% 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Mexico Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 325040. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, 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.