The NM Behavioral Health Institute at Las Vegas
3695 Hot Springs Boulevard, Las Vegas, NM 87701 · Government - State · 162 certified beds · (505) 454-2100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,353 in federal fines (most recent 2024-08-23)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 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 | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.8% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.8% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.4% | 0.9% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 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 | 7.3% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.6% | 11.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 23.8% | 14.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 98.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.2% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 43.4% | 14.5% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.45 | 1.65 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.75 | 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.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 data for this measure is missing or was not submitted. 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 162 beds and averages 107.4 residents a day — about 66% occupied, or roughly 55 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.78 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.82 hrs/resident/day on weekends vs 4.18 on weekdays — 9% thinner on weekends. RN hours go from 0.70 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2024-08-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
Based on record review and interview, the facility failed to prevent abuse for 1 (R #79) of 1 (R #79) resident reviewed when the facility staff failed to recognize the difference between horseplay and unwanted touching and harassment between a staff and resident. This deficient practice likely resulted in R #79 increase of isolation and fear of further abuse. The findings are: A. On 08/19/24 at 2:47 pm, during an interview with R #79, she stated. One of the activities persons kicked me in the ass (buttocks). They (staff) thought she was messing around. I did not think she was messing around, she kicked me. That's not funny. They sent her home for a couple of days. I felt bad because she [Activities Assistant (AA) #1] might have a ton of bills to pay or whatever. This happened on August first. I told (name of Registered Nurse #1). After that I kind of just stayed in my room because I didn't want to see her [AA #1] or do activities when she is there. She might do it again. I don't want to cause trouble and they will make me leave here (facility). R #79 further stated that she has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-12-12 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide documentation confirming 2 (NA #1 and NA #3) of 5 (NA #1, NA #3, NA #4, and NA #5) Nurse Aides had 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 102 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: NA #1:A. Record review of NA #1's personnel record revealed the following:1. NA #1's is a current employee with a hire date of [DATE]. NA #1's date of Certified Nurse Aide Training was completed on [DATE].3. NA #1 is not certified and has not taken her certification test as of [DATE].NA #3:B. Record review of NA #3's personnel record revealed the following:1. NA #3's is a current employee with an original hire date of [DATE], rehire on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-12-12 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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's Administrator (ADM) and Director of Nursing (DON) failed to administer the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring staff were trained and/or competent before providing care to residents. 2. Allowing untrained and uncertified nurse aides to train other nurse aides. These deficient practices are likely to affect all 102 residents residing in the facility according to the daily census provided by the Admissions Coordinator (AC) on [DATE] and could lead to residents not maintaining their highest practicable physical, mental, and social well-being. The findings are: A. Record review of the facility's progress notes for R #12 revealed on [DATE] R #12 had fallen out of mechanical lift sling while being transferred by Nurse Aide (NA) #1 and NA #2. R #12 landed on the floor and was lying on his back, left leg was under bed, right leg propped on bed, and laceration (a wound…
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 · E2025-12-12 · tag F0657 — failed to keep the care plan current — patternDevelop 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 record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #29) of 3 (R #1, R #29, and R #32) residents reviewed when staff failed to update a care plan after a resident was diagnosed with dementia. This deficient practice could result in residents' care and needs not being addressed. The findings are:A. Record review of R #29's admission Record revealed she was admitted to the facility on [DATE].B. Record review of R #29's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/09/25, revealed the following:1. R #29's most recent admission or reentry to this facility was on 05/13/22.2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) was not conducted because the resident is rarely or never understood.3. R #29's active diagnoses include a diagnosis of Non-Alzheimer's Dementia (a variety of dementia types that are not caused by Alzheimer's disease which is a type mental…
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 · E2025-12-12 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to ensure the annual performance review for the certified nursing assistants (CNAs) was completed for 1 (CNA #2) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed. This could lead to residents not receiving the care and services as described on the care plan. The findings are:A. Record review of the facility's Personnel Records revealed CNA #2's hire date of 05/18/13. The most recent annual performance evaluation for CNA #2 was dated 10/29/24. B. On 12/12/25 at 11:43 am during an interview, the Director of Nursing (DON) could not confirm if CNA #2 had an annual performance evaluation completed since 10/29/24 and stated, [Name of city where this facility's Human Resources office is located] keeps up with the evaluations, they are sent to me when it is time for the employees to sign the yearly evaluation. She stated that she does expect the evaluations to be completed every 12 months.
- Potential for harm · E2025-12-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interviews, the facility failed to properly store medications in the facility by making sure:-Medications in bubble wraps are not compromised (not opened or punctured and secured in the original packaging from the pharmacy). -All medical supplies are not expired.These deficient practices are likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication.The findings are:A. On 12/10/25 at 9:07 am during an observation of the medication cart, in the locked unit, revealed the following:-A medication bubble card labeled with the name of R #70 and containing Clonazepam (a prescribed medication used to manage anxiety) 1 mg (milligrams). The bubble pack labeled number 1 had a small green pill in the bubble. The bubble had been opened.- A 25g (gauge refers to the size of the hole in a needle) needle with an expiration date of 09/10/25.B. On 12/10/25 at 9:07 am, during an interview with Licensed Practical Nurse (LPN) #1, 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 · D2025-12-12 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify a resident's representative of a transfer or discharge and the reasons for the move in writing prior to the transfer or discharge for 1 (R #104) of 3 (R #29, R #104, and R #106) residents reviewed for transfers and discharges. This deficient practice could lead to residents' representatives being unaware of the residents' health status. The findings are:A. Record review of R #104's admission Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) dated 09/04/25, revealed the following: 1. R #104 was admitted to the facility on [DATE] with the following diagnoses:- Epilepsy (a seizure disorder),- Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), - Human Immunodeficiency Virus (HIV; a virus that attacks the body's immune system),- Personal history of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 #19 and R #32) of 4 (R #8, R #15, R #19, and R #32) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are:R #19 A. Record review of R #19's admission Record revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease (a progressive mental deterioration), unspecified, 2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 3. Essential (primary) hypertension (HTN; high blood pressure). B. Record review of R #19's progress notes revealed the following: 1. On 09/05/25 at 7:45 am, facility staff found R #19 asleep in a chair in the activity room. When staff woke R #19 up and assisted her to get…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record 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) within 48 hours of admission for 2 (R #1 and R #19) of 3 (R #1, R #19, and R #29) 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 #1 A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Chronic viral hepatitis C (inflammation of the liver), 2. Chronic obstructive pulmonary disease (COPD; lung disease), 3. Dependence on supplemental oxygen, 4. Personal history of traumatic brain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (R #32) of 1 (R #32) resident reviewed who was identified as having a hearing impairment and utilizing a hearing aid. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].B. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.C. Record review of R #32's care plan dated 11/29/25 revealed the care plan did not contain any information on R #32's hearing aid use.D. Record review of R #32's annual MDS (minimum data set) assessment dated [DATE] revealed the following:-Section B0200: Moderate difficulty (hearing), speaker has to increase volume and speak distinctly.-Section B0300: No hearing aid or other hearing appliance used.E. On 12/08/25 at 10:11 am 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.
- Potential for harm · D2025-12-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #11) of 1 (R #11) resident when the staff failed to follow physician order for derma saver palm pillow (a pillow to keep fingernails from digging into palms) to R #11's right hand. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: A. Record review of R #11's face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including, but not limited to:-Cerebrovascular accident (or CVA, is a medical term that refers to types of strokes), TIA (A transient ischemic attack is a short period of symptoms similar to those of a stroke), or stroke (can occur when blood flow to the brain is blocked or there is sudden bleeding in the brain).-Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down).B. Record review of the 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.
Show the remaining 15 citations
- Potential for harm · D2025-12-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for 1 (R #32) of 1 (R #32) resident reviewed. This deficient practice had the potential to result in unmet hearing needs, miscommunication, and decreased participation in daily activities. The findings are: A. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].B. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.C. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair hearing aids were on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-12 · tag 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (R #8) of 1 (R #8) resident observed for food preferences. This deficient practice is likely to result in food intolerance and/or an allergic reaction to the food being served to the residents. The findings are:A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE].B. Record review of R #8's meal card (card that identifies what to serve or not serve each resident) revealed R #8 is not to have chocolate and is allergic to peas. C. On 12/09/25 at 11:31 am, during an observation of dining, R #8 was served his lunch meal, on his plate was pasta that contained peas. Also noted on his tray was a bowl of chocolate pudding. R #8 stated to staff that he could not eat that because he is allergic to peas and chocolate.D. On 12/09/25 at 11:33 am during an interview with Certified Nurse Aide (CNA #1), she stated R #8's meal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure resident records were accurate for 1 (R #15) of 3 (R #12, R #15, and R #77) residents reviewed for catheter care (proper cleaning and maintenance of a catheter). This deficient practice could likely cause staff confusion and residents to get care and services that are not needed. The findings are: A. Record review of R #15's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified bilateral hearing loss (reduction of hearing ability in both ears),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety),4. Calculus in bladder (bladder stones; hard mineral deposits that form in the bladder),5. Benign prostatic hyperplasia with lower urinary tract symptoms (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 · F2024-08-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Perform hand hygiene and to change gloves as often as necessary to avoid cross contamination, - Store open food protected and with labels and dates to prevent cross contamination and outdated usage, - Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen, - Use the sanitizing solution according to manufacturer's instructions, - Protect clean disposable wares (includes dishware, drinkware, and flatware such as spoons, forks, and knives) to prevent contamination, These failures had the potential to result in cross contamination and foodborne which could affect all residents who ate food from the kitchens. The findings are: Handwashing and Glove Use A. Record review of the facility's Sanitation and Infection Control, Hand Hygiene policy, dated January 2014, revealed staff directed to wash hands with soap and water at the following times: - Before handling food or clean utensils, dishes, equipment, -…
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 · E2024-08-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 1 (R #16) of 1 (R #16) residents reviewed when staff failed to update wound care treatment orders according to R #16's care plan and in relation to R #16's pressure ulcer becoming worse. This deficient practice is also likely to lead to residents developing more/other pressure ulcers and wounds worsening. The findings are: A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE]. B. Record review of R #16's care plan dated 07/09/24 revealed, Focus: Impaired skin integrity related to Stage II [2] pressure injury (level of skin damage which results from unrelieved pressure on the body) to coccyx (tailbone). Interventions: If pressure injury is not improving within 2 weeks of using current…
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 before2024-08-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that 1 (R #16) of 1 (R #16) residents reviewed was free from accidents and hazards. Facility was using a call light attached to R #16's clothing to alert staff when resident attempts to transfer on her own. Call light would detach from the wall and ring and staff would be alerted that resident was attempting to transfer self. This deficient practice is likely to put residents at risk of unsafe situations. The findings are: A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE]. B. Record review of R #16's nursing progress notes dated 06/09/24 through 06/10/24 revealed the following: 1. 06/09/24: R #16 was found on the floor next to her bed by staff. R #16 was attempting to use the restroom on her own prior to fall and told staff her left hip hurt badly. R #16 was transported to the emergency room (ER). 2. 06/10/24: R #16 was diagnosed with two fractures in the ER and returned to 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 · E2024-08-23 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to have recipes for all menu items and to ensure staff followed nutritionally calculated recipes for pureed diets. This failure had the potential for food not to meet the nutritional requirements of all residents who ate pureed foods. The findings are: A. On 08/20/24 at 8:55 am, during an interview, the Supervisor stated the menu for the resident's lunch was pork enchiladas, mixed vegetables, beans, and fruit. She stated the alternative was egg salad sandwich, and residents with a pureed diet were having pureed carrots instead of pureed mixed vegetables. B. Observation on 08/20/24 at 8:56 am revealed the Supervisor prepared pureed enchiladas for the residents' lunch service. She placed six corn tortillas (six inch), six servings of enchilada mixture, and scooped an unmeasured amount of thickening powder into a food processor. The Supervisor pureed the mixture to a pudding consistency. C. On 08/20/24 at 8:58 am during an interview, the Supervisor stated the scoop for the thickening powder was equal to one cup.…
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 before2024-08-23 · tag F0806 — failed to honor food preferences — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide food that accommodated resident preferences for 2 (R #9 and R #69) of 2 (R #9 and R #69) residents reviewed for food preferences. This deficient practice is likely to result in weight loss due to the residents not eating or an allergic reaction to the food being served to the residents. The findings are: A. Record review of R #69's face sheet revealed, R #69 was admitted into the facility on [DATE]. B. Record review of R #69's care plan dated 7/10/2024, revealed the following: -Focus: Diet is Therapeutic Diet.(diet modified to fit the nutrition need of a resident) -Interventions: Provide diet as ordered and honor all food preferences. C. Record review of facility incident report form dated 03/20/24, R #69 requested a chicken sandwich (choice #2 ) for dinner. R #69 did not receive chicken sandwich as ordered because the dietary had only sent three chicken sandwiches for the unit. D. Record review of facility incident report form dated 03/20/24,…
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 · E2024-08-23 · tag F0825 — patternProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to meet professional standards of care for 3 (R #8, #42, and #52) of 3 (R #'s #8, #42, and #52) residents reviewed by not providing restorative nursing services (a type of rehabilitation that helps residents regain or maintain their independence and physical abilities) as ordered by a physician. This deficient practice is likely to result in the resident experiencing psychosocial harm (harm to someone's mental health) and despair. The findings are: R #8: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. B. Record review of R #8's physician order/referral dated 07/10/24 revealed R #8 was to receive restorative nursing services weekly that focused on Upper extremity [arms] exercises that focus on range of motion (ROM). C. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #8 was offered/provided six (6) restorative nursing sessions out eight (8)…
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 · E2024-08-23 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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 Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 2 (CNAs #1 and #2) of 5 (CNAs #1, #2, #3, #4, and #5) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #1: A. Record review of the facility staffing list revealed CNA #1 was hired on 04/30/22. B. Record review of CNA #1's annual required in-service training revealed CNA #1 had only completed 8 out of 12 hours of required training by hire date. C. Record review of the facility staffing schedule dated 06/23/24 through 08/23/24 revealed CNA #1 worked 124 total shift hours during that timeframe. CNA #2: D. Record review of the facility staffing list revealed CNA #2 was hired on 06/17/17. E. Record review of CNA #2's annual required in-service training revealed CNA #2 had only completed 10 out of 12 hours of required training by hire date. F.…
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 · D2024-08-23 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 staff failed to immediately report a witnessed incident of abuse to a supervisor and the facility failed to report an incident of abuse to the state survey agency within 2 hours for 1 (R #79) of 1 (R# 79) resident reviewed for incidents/accidents. If the facility fails to report incidents of abuse to the State Agency, then the implementation of measures to prevent further abuse is delayed. The findings are: A. On 08/19/24 at 2:47 pm, during an interview with R #79, she stated. One of the activities persons kicked me in the ass (buttocks). They (staff) thought she was messing around. I did not think she was messing around, she kicked me. That's not funny. They sent her home for a couple of days. This happened on August first. I told (name of Registered Nurse #1). After that I kind of just stayed in my room because I didn't want to see her [AA #1] or do activities when she is there. She might do it again. I don't want to cause trouble and they will make me leave here (facility). R #79 further stated that she has participated less 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 · E2023-07-21 · 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
Based on observation, record review, and interview, the facility failed to maintain oxygen equipment according to professional standards for 2 (R #8 and R #17) of 3 (R #8, R #17, and R #53) residents reviewed for respiratory care by not ensuring the posting of caution and safety signs indicating the use of oxygen in the resident's room and This deficient practice could likely result in: Staff not recognizing that oxygen is being used in a residents room, this could result in a dangerous (able or likely to cause harm or injury), firehazard (material, substance, or action that increases the likelihood of an accidental fire occurring). A. Record review of the facility policy, Medical Oxygen Handling and Storage, last revised 07/13/20, revealed, Procedures. IV. All rooms with oxygen tanks/concentrators will be labeled with O2 (oxygen) precautions. Signs may be obtained from the safety department. Protocol. 3. Appropriate signage must be placed on the door of the patient's using oxygen. Resident #8: B. Record review of physician's orders for R #8 revealed the following orders related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that 1 (R #21) out of 1 (R #21) resident was safely transferred from bed to wheelchair using two staff members. This deficient practice has the potential to cause an accident when two staff members aren't used to transfer a resident who requires a mechanical lift (a lift that helps residents move from bed to wheelchair etc .). The findings are: Resident #21: A. On 07/18/23 around 10:00 am, an observation of an unidentified Certified Nursing Assistant (CNA) was answering R #21's call light. Unidentified CNA came out of R #21's room a few minutes later and walked down the hall. A few minutes later unidentified CNA came back to the room with a Sara lift (a mechanical lift used to assist residents with transferring when they can't lift their full body weight). She went back into R #21's room with the Sara lift and approximately 10 to 15 minutes later, unidentified CNA came back out of R #21's room with a bag of trash and the Sara lift. B. On 07/18/23 around 10:30 am, during observation and interview with 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 · D2023-07-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that residents are free of any significant medication errors for 1 (R #22) of 1 (R #22) resident reviewed for medication administration, when they failed to administer medication without regard to manufacturer's instructions for administration. Residents may likely not experience the maximum benefit intended and fail to achieve their highest level of well-being. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication due to it not being administered as prescribed. The findings are: A. On 07/19/23 at 8:23 am, during an observation of medication administration to R #22 by Registered Nurse (RN) #5, the medication prescribed, Fenofibrate Nano crystallized (a medication prescribed to lower cholesterol levels in the blood) 1 tablet was opened and then crushed by RN #5 and added to applesauce before being given to R #22. B. Record review of the U.S. Food and Drug…
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 · B2023-07-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to provide proper infection control practices by not performing hand hygiene between resident care for 4 (R #12, R #22 R #47, and R #76) out of 4 (R #12, R #22, R #47, and R #76) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between residents and/or staff. The findings are: A. On 07/19/23 at 8:20 am, during an observation of the medication pass for R #12, Registered Nurse (RN) #5 failed to perform hand hygiene prior to passing R #12's medication, and after passing R #12's medication no hand hygiene was performed before RN #5 went on to the R #22. B. On 07/19/23 at 8:24 am, during an observation of the medication pass for R #22, RN #5 put on gloves prior to passing medication, however, no hand hygiene was done before she put on gloves, or after taking them off. C. On 07/19/23 at 11:03 am, during an observation of the medication pass for R #76, RN #6 failed to complete hand hygiene prior to passing R #76's medication, and after passing R #76's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$18,353 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $18,353 — penalty dated 2024-08-23
- Medicare payment denial — starting 2024-09-25 for 9 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| JARAMILLO, CHARLES | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2008 |
| MARTINEZ, DARLENE | Individual | W-2 MANAGING EMPLOYEE | since 04/01/2015 |
| STATE OF NEW MEXICO | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 08/24/2009 |
CMS files one row per role, so the 4 rows in the source record cover these 3 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.
1 organizational owner 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.
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 325104. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-12, 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 →
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