Mescalero Care Center
454 Lipan Avenue, Mescalero, NM 88340 · Non profit - Other · 40 certified beds · (575) 464-4802 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (63) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
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) | 1 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 fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.0% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 2.6% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.7% | 0.9% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.0% | 6.5% | check this* — see note marked star 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 | 3.2% | 3.5% | 3.3% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 16.7% | 14.7% | 18.9% | better |
| Long-stay residents with pressure ulcers | 7.8% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.6% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.1% | 14.5% | 17.1% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% 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 | 52.5%CMS range 38.9–66.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 7.8–18.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. 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 number of residents or resident stays is too small to report. 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 number of residents or resident stays is too small to report. 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 number of residents or resident stays is too small to report. 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 number of residents or resident stays is too small to report. 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 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 | not reported — The number of residents or resident stays is too small to report. 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 number of residents or resident stays is too small to report. 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 | 7.2%CMS range 3.2–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. Inspectors cited this home for failing to submit its staffing data to CMS (F0851) — see the citation below; CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
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.
63 citations, most serious first. The 10 most serious are shown; the remaining 53 are one tap away and print in full.
- Potential for harm · Ecited before2026-06-10 · tag F0628 — patternProvide 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 provide the required transfer information for 3 (R #8, R #9, and R #10) of 3 (R #8, R #9, and R #10) residents reviewed for transfers when staff failed to: 1. Notify R #8, R #9, and R #10 and their representative(s) of the residents' transfer to the hospital in writing and in a language and manner they understand.2. Ensure R #8, R #9, R #10 and their representative(s) receive a written notice of bed hold which indicated the duration the resident's bed would be held.These deficient practices could likely result in the residents and/or their representatives not knowing the reason for the transfer, the location of the transfer, their rights to advocate and make informed decisions. The findings are:R #8A. Record review of R #8's admission Record, no date, revealed R #8 was admitted to the facility on [DATE]. B. Record review of R #8's nursing progress notes, revealed the following:1. On 03/21/26 R #8 was sent to the hospital due to altered mental status.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 · E2025-12-05 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R #24A. Record review of R #24's admission documents, no date, revealed R #24 was admitted to the facility on [DATE]. B. Record review of an incident report for R #24 submitted to the state agency, dated 10/10/25, revealed the following: 1. Incident date 09/17/25.2. On 09/17/25, R #24 reported that Business Office Manager (BOM) #1 never let him know how much money he had in his account. C. Record review of R #24's personal fund transaction history, dated 01/01/25 to 11/30/25, revealed the following: 1. R #24's balance on 07/24/25 was $7,208.42.2. The last transaction documented in R #24's account was dated 07/24/25. 3. R #24 received monthly deposits for the same amount. 4. Staff did not document any deposits or withdrawals from R #24's account after 07/24/25. D. Record review of R #24's quarterly financial statement, dated 09/30/25, revealed the amount in R #24's account was $7,208.42 (the same as the amount listed on the financial history report that ended on 07/24/25). R #25E. Record review of R #25's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-05 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 protect residents from abuse, neglect, and exploitation for 3 (Anonymous R #1, Anonymous R #2, and R #24) of 5 (Anonymous R #1 and Anonymous R #2, R #24, R #25, R #26) residents sampled for abuse, neglect, and exploitation for the following:1. The Business Office Manager (BOM) #1 attempted to exploit R #24's resident funds in the amount of $7208.42. 2. BOM #1 was witnessed on two separate occurrences in the front lobby and in resident common area yelling at other staff members. 3. Anonymous R #1, Anonymous R #2 are fearful of retaliation (getting kicked out of the facility) for speaking out against BOM #1 who is directly related to the tribal leadership. These deficient practices could result in facility not maintaining a safe environment for residents' psychosocial wellbeing, residents could experience feeling powerless, violated, fearful, and unsure of how to regain control over their lives and continue to trust staff and feel safe in their home. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-05 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to meet professional standards of practice for medication administration for 5 (R #16, R #17, R #18, R #19, and R #25) of 8 (R #16, R #17, R #18, R #19, R #21, R #22, R #23, and R #25) residents reviewed for medication administration when staff failed to ensure medications were prepared immediately before medication administration for each resident.This deficient practice could likely lead to the residents receiving the incorrect medications and could cause adverse effects (an undesired harmful effect resulting from a medication or other intervention). The findings are: A. On 12/04/24 at 7:27 AM, during an observation of medication administration revealed the following: 1. LPN #16's medication cart had five (5) medicine cups with pills in them.2. Four (4) of the medication cups had initials on them.3. One of the medication cups with initials had one (1) pill in it.4. One of the medication cups with initials had five (5) pills in it.5. One of the medication cups with initials had two (2) pills in it6. One of the medication cups…
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 · D2025-12-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report allegations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) to the State Agency within 24 hours of the allegation for 1 (R #24) of 5 (R #24, R #25, R #26, R #27, and R #28) residents reviewed for misappropriation of property. If the facility fails to report allegations of misappropriation of property to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their belongings are not being protected. The findings are: A. Record review of R #24 admission documents, no date, revealed R #24 was admitted to the facility on [DATE]. B. Record review of the initial incident report submitted to the state agency, dated 10/10/25, revealed the following: 1. Incident date 09/17/25 (incident submitted on 10/10/25, not…
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 · F2025-05-19 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on an interviews the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. This failure could potentially affect all 29 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided 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.
- Potential for harm · Fcited before2025-05-19 · 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
Recite from 05/22/24 Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 29 residents in the facility (residents were identified by resident matrix provided by the Administrator on 05/12/25) who eat food or drinks stored in the nutrition refrigerator or freezer when staff failed to: 1. Maintain refrigerator temperatures in the nutrition refrigerators (refrigerator near the nursing station that contains drinks and snacks for residents). 2. Food stored in the nutrition refrigerator was not expired. 3. Food stored in the nutrition refrigerator or freezer had an expiration date. 4. Food that was supposed to be frozen was not thawed in the refrigerator. If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 05/15/25 at 11:53 AM, during an observation of the nourishment room refrigerator revealed there…
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 · E2025-05-19 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and heart rate outside of set parameters) for 1 (R #1) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications, when staff failed to notify the provider that R #1's blood pressure was high and R #1's pulse was low. This deficient practice could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors). B. Record review of R #1's physician orders revealed the following: 1. Amlodipine (high blood pressure primarily used to treat high blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-19 · 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, observation, and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. They are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary for 6 (R #9, R #10, R #11, R #118, R #119, and R #130) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications, when staff failed to: 1. Psychotropic medications for R #118 and R #119 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Psychotropic medications that were ordered to be given as needed (PRN) for R #119 were not prescribed for longer than 14 days without a rationale from the provider for why the medication was needed for longer than 14 days. 3. Carry out a gradual dose reduction (GDR;…
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 before2025-05-19 · tag F0628 — patternProvide 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 provide the required discharge or transfer information to the resident and the resident's representative(s) in writing for 3 (R #8, R #11, and R #119) of 3 (R #8, R #11, and R #119) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the resident and the resident's representative of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #8. 2. Complete a discharge summary for R #8 that included the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status including an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one…
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 53 citations
- Potential for harm · E2025-05-19 · 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 interview and record review, the facility failed to ensure the Minimum Data Set Assessment were accurate for 3 (R #9, R #118 and R #121) of 9 (R #1, R #4, R #9, R #10, R #118, R #119, R #121, R #130 and R #131) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #9 A. Record review of R #9's admission record revealed R #9 was admitted on [DATE]. B. Record review of R #9's physician's orders revealed an order for Smaglutide (non-insulin medication used to help improve blood sugar control) subcutaneous (fatty tissue layer just beneath the skin) solution, inject 1 mg every Sunday for diabetes mellitus type 2 (DM 2; chronic disease characterized by high levels of sugar in the blood). Start date: 12/08/24. C. Record review of R #9's Quarterly MDS dated [DATE] revealed the following: 1. Section N0350, Insulin (hormone that helps lower blood sugar levels) a. Staff documented 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 · Ecited before2025-05-19 · 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 Recite from 05/22/24 Based on record review and interview, the facility failed to ensure care plan revisions occurred for 4 (R #9, R #11, R #118, and R #130) of 6 (R #9, R #11, R #118, R #119, R #121, and R #130) residents when the staff failed to revise the care plan with the most current resident information. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #9 A. Record review of R #9's admission Record (no date) revealed R #9 was admitted to the facility on [DATE]. B. Record review of R #9's CNA shower review forms dated 02/03/25 through 05/15/25 revealed the following: 1. R #9 was offered showers twenty-three times. 2. R #9 refused her showers eleven of the twenty-three times showers were offered to her. C. Record review of R #9'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 before2025-05-19 · 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, record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #1 and R #121) of 2 (R #1 and R #121) residents reviewed for unnecessary medication use and wound care when staff failed to: 1. Notify the physician about R #1's elevated blood pressure as indicated on physician's order. 2. Obtain wound care orders prior to performing wound care on R #121's right leg. If the facility is not providing care per physician's orders and care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of essential (primary) hypertension…
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 · E2025-05-19 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 1 (R #4) of 1 (R #4) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are: A. Record review of R #4's admission record no date revealed an admission date of 09/05/23. B. Record review of R #4's Annual MDS assessment dated [DATE] revealed R #4's personal preferences for activities. C. Record review of R #4's care plan dated 09/30/24 revealed R #4's care plan did not include her personal preferences from the MDS Annual Assessment. D. Record review of R #4's Activity Individual Participation 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 · Ecited before2025-05-19 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 05/22/24 Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 60 days for 4 (R #1, R #9, R #10, and R #118) of 5 (R #1, R #9, R #10, R #118, and R #130) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: R #1 A. Record review of R #1's Electronic Medical Record (EMR) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 was seen by the Medical Director (clinician who oversees and guides the care provider to nursing home residents) on 12/29/24. 3. R #1 was seen by the Medical Director on 05/10/25. B. On 05/19/25 at 3:13 PM, during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days. R #9 C. Record review of R #9's EMR revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9…
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 before2025-05-19 · 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 interview and record review, the facility failed to complete performance reviews at least every 12 months for 1 (CNA #26) of 2 (CNA #26 and CNA #28), CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of CNA #26's employee files revealed the following: 1. CNA #26's hire date was 07/18/11. 2. CNA #26's last performance review was 02/20/24. B. On 05/19/25 at 2:48 PM during an interview, the Human Resource Manager confirmed that the last performance evaluation for CNA #26 was 02/20/24.
- Potential for harm · E2025-05-19 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 4 (R #9, R #10, R #11 and R #118) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #9 A. Record review of R #9's admission record, no date, revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-19 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Recite from 05/22/24 Based on record review and interview the facility failed to ensure residents obtained dental services for 3 (R #9, R #10 and R #123) of 4 (R #9, R #10, R #121 and R #123) residents sampled for dental services, when staff failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R #9 A. On 05/12/25 at 2:15 PM, during an interview, R #9 stated that she needed to have her dentures checked because they were loose. B. Record review of R #9's admission Record, no date, revealed an admission date of 09/16/24. C. Record review of R #9's physician's order dated 09/16/24 revealed Dental consult as needed. D. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #9 had not been seen by a dentist since her admission. 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 · Ecited before2025-05-19 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 05/22/24 Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #9 and R #118) of 6 (R #1, R #9, R #10, R #118, R #130 and R #131) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #9 A. Record review of R #9's physician orders revealed the following: 1. An order dated 11/25/24 for acetaminophen (Tylenol; analgesic medication used to treat mild to moderate pain) tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for pain. B. Record review of R #9's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following: 1. On 04/06/25 at 3:01 AM, staff documented acetaminophen was given for a pain level of 5 (pain scale 1-10, 10 highest). 2. On 04/08/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-19 · tag F0941 — patternDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory Effective Communication training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of RN #24's Online Training Transcript, no date revealed effective communication training was not completed. B. Record review of LPN #25's Online Training Transcript, no date revealed effective communication training was not completed. C. Record review of CNA #26's Online Training Transcript, no date revealed effective communication training was not completed. D. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that Effective Communication Training has not been completed for RN #24, LPN #25, and CNA #26.
- Potential for harm · E2025-05-19 · tag F0942 — patternEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide resident rights training (training that helps staff promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination) for 4 staff (RN #24, LPN #25, CNA #26, and RN #27) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff sampled for training. This deficient practice could likely result in staff being unaware of residents rights resulting in negative psychosocial well-being for residents. The findings are: A. Record review of staff training records revealed RN #24 did not complete training for resident rights. B. Record review of staff training records revealed LPN #25 did not complete training for resident rights. C. Record review of staff training records revealed CNA #26 did not complete training for resident rights. D. Record review of staff training records revealed RN #27 did not complete training for resident rights. E. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that RN #24, LPN #25, CNA #26, and RN #27 did…
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 · E2025-05-19 · tag F0944 — patternConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory QAPI (Quality Assurance/Performance Improvement) training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions. The findings are: A. Record review of the employee training transcript, no date, revealed RN #24 did not complete QAPI training. B. Record review of the employee training transcript, no date, revealed LPN #25 did not complete QAPI training. C. Record review of the employee training transcript, no date, revealed CNA #26 did not complete QAPI training. D. On 05/19/25 2:48 PM, during an interview, the Human Resource Manager confirmed that the QAPI training has not been completed for RN #24, LPN #25, and CNA #26.
- Potential for harm · E2025-05-19 · tag F0945 — failed to train staff on abuse prevention — patternInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to provide infection control training (training that helps staff recognize various infection control prevention to help stop the spread of infections) for 2 (RN #24 and CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff sampled for training. This deficient practice could likely result in inadequate infection control, and can lead to increased spread of resistant organisms, and risk of infections among residents and staff. The findings are: A. Record review of staff training records revealed CNA #26 completed training for infection control on 11/11/22. B. Record review of staff training records revealed RN #24 completed training for infection control on 12/31/23. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that CNA #26 and RN #24 did not complete the training for the year 2025. The HRM confirmed that the training should be completed annually.
- Potential for harm · Ecited before2025-05-19 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure that each CNA received a minimum of 12 in-service hours a year based on hire date for 1 (CNA #26) of 2 (CNA #26, and CNA #28) CNAs sampled for training. If CNAs are not adequately trained, they are unable to provide the necessary care and services to residents. The findings are: A. Record review of the facility's CNA training records revealed the following: 1. CNA #26 hire date was 07/18/11. 2. CNA #26 had 1 training in-service hour taken on 11/22/24. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that CNA #26 did not have the minimum of 12 in-service hours a year.
- Potential for harm · D2025-05-19 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 2 (R #119 and R #130) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: R #119 A. Record review of R #119's physician's orders revealed an order dated 04/29/25 for trazadone (antidepressant medication) 25 mg as needed for sleep related to systolic (congestive) heart failure (occurs when the heart's left ventricle cannot contract effectively, leading to insufficient blood being pumped to the body). B. Record review of R #119's medical record revealed staff did not document consent for trazadone. C. On 05/19/25 at 2:12 PM, during an interview, the Director of Nursing (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-19 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 05/22/24 Based on record review and interview, the facility failed to ensure a comprehensive MDS was completed within 14 calendar days after admission for 1 (R #12) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) residents reviewed for MDS. This deficient practice could likely result in residents' care needs not being met. The findings are: A. Record review of R #12's admission record no date revealed an admission date of 12/17/24. B. Record review of R #12's admission MDS assessment dated [DATE] revealed the admission MDS assessment was accepted on 01/06/25. C. On 05/19/25 at 1:21 PM, during an interview with the MDS Coordinator, she confirmed R #12's admission MDS assessment was not completed within 14 days of admission. The MDS Coordinator confirmed that the admission MDS assessments should be completed within 14 days of admission.
- Potential for harm · D2025-05-19 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 a significant change (major decline or improvement in the patient's health status) MDS Set assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #3) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R # 9, R #11, and R #12) resident reviewed for MDS. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are: A. Record review of R #3's admission record no date revealed an admission date of 03/24/25. B. Record review of R #3's physician orders dated 03/26/25 revealed an order for palliative care (an interdisciplinary medical care-giving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses). C. Record review of R #3's nursing progress note dated 03/26/25 revealed R #3 was placed on Palliative Care due to 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 · D2025-05-19 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure that an MDS was completed every three months for 2 (R #1, and R #9) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) resident reviewed for MDS assessments, when they failed to complete quarterly MDS assessments timely (completed 92 days after the previous assessment reference date (ARD)). This failed practice could result in residents' assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #1's quarterly MDS assessments revealed the following: 1. Quarterly MDS accepted 01/06/25. 2. Quarterly MDS accepted 04/07/25. B. Record review of R #9's quarterly MDS assessments revealed the following: 1. Quarterly MDS accepted 01/06/25. 2. Quarterly MDS accepted 04/13/25. D. On 05/19/25 at 1:21 PM, during an interview with the MDS Coordinator confirmed that R #1's, and R #9's, Quarterly MDS assessments were not completed on time.
- Potential for harm · Dcited before2025-05-19 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of 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 have MDS assessments completed, submitted, and finalized in a timely manner (within 14 days of completion) for 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) of 9 (R #1, R #2, R #3, R #4, R #5, R #6, R #9, R #11, and R #12) residents reviewed for MDS assessments. If MDS assessments are not completed, submitted, and finalized in a timely manner, it is likely that residents will receive less than optimal care. The findings are: R #1 A. Record review of R #1's admission record revealed that R #1 was admitted on [DATE]. B. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #1 revealed R #1 MDS target date (Assessment Reference Date) on 12/25/24 and was not received. R #2 C. Record review of R #2's admission record revealed that R #2 was admitted on [DATE]. D. Record review of the MDS 3.0 Missing OBRA Assessment Report for R #2 revealed R #2 MDS target date on 01/01/25 and was not received. R #3 E. Record review of R #3's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-19 · 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) for 1 (R #119) of 1 (R #119) resident reviewed for unnecessary medication use. 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: A. Record review of R #119's admission Record, no date, revealed R #119 was admitted into the facility on [DATE]. B. Record review of R #119's medication list from the hospital, no date, revealed an order for trazadone (antidepressant medication) 50 mg, give 0.5 mg as needed for sleep. C. Record review of R #119's physician's order, dated 04/29/25, revealed an order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-19 · 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 Recite from 05/22/24 Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #4 and R #9) of 12 (R #1, R #4, R #9, R #10, R #11, R #118, R #121, R #122, R #123, R #124, R #130 and R #131) residents reviewed for comprehensive care plans (plan that has measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #4 A. Record review of R #4's admission record no date revealed an admission date of 09/05/23. B. Record review of R #4's MDS Assessment revealed the Annual MDS Assessment was completed on 09/18/24. The MDS included R #4's personal preferences for activities. C. Record review of R #4's care plan dated 09/30/24 revealed staff did not document on the care plan R #4's personal preferences for activities. D. On 05/14/25 at 9:26 AM, during an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-19 · 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 observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #118) of 3 (R #11, R #118, and R #119) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #118 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed. The findings are: A. Record review of R #118's admission documents, no date, revealed the following: 1. R #118 was admitted to the facility on [DATE]. 2. R #118 had the following diagnoses: a. History of falling. b. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). B. On 05/12/25 at 3:47 PM during an interview with R #118's family member (FM) #1 the following was revealed: 1. R #118 fell approximately four weeks prior to the interview (FM #1 was unsure of the date). 2. R #118 tried to get out of bed on her own. 3. The facility placed a fall mat and R #118's bed in lowest position when…
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 · D2025-05-19 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to provide abuse, neglect, and exploitation training to 1 staff (RN #24) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation. The findings are: A. Record review of RN #24's training transcript, no date, revealed that abuse, neglect, and exploitation training was last completed 12/31/23. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that RN #24 did not complete the required training since 2023. The HRM confirmed that the training should be completed annually.
- Potential for harm · Dcited before2025-05-19 · tag F0949 — failed to train staff on dementia and abuse — isolatedProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — the official record, unedited, may be distressing
Recite from 05/22/24 Based on record review and interview, the facility failed to provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 1 (CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of the staff training records revealed CNA #26 did not complete training for behavioral health needs. B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that CNA #26 did not complete the training for the year 2025. The HRM confirmed that the training should be completed annually.
- Potential for harm · E2025-02-27 · tag F0561 — failed to honor residents' choices — patternHonor 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
Past Noncompliance Based on interview and record review, the facility failed to promote resident self-determination (the ability to make your own choices and decisions without being controlled by others) for 3 (R #1, R #2, and R #3) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for choices when staff did not accommodate the residents wishes to go out into the community. If the facility does not honor residents' choices, then residents are likely to feel a loss of independence and self-worth leading to feelings of frustration and depression. The findings are: A. Record review of an anonymous complaint dated 11/13/24 revealed residents haven't left the facility for anything other than medical appointments for over a year and residents would like to go shopping. B. On 02/27/25 at 10:45 AM during an interview, the Activities Director stated the following: 1. She used to take residents out into the community to go shopping and to the casino. 2. The facility has not been taking residents out into the community for several years. 3. The facility did not return to their regular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-22 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to provide services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficient practice could affect all 25 residents, as identified on the facility census list provided by the Director of Nursing on 05/19/24. This deficient practice could likely result in residents not receiving the services they need for optimal quality of care. The findings are: A. Record review of the staff timesheets from 04/22/24 through 05/21/24 revealed that the facility did not have an RN present for 8 consecutive hours on the following dates: 1. 04/26/24 RN hours worked were 5 hours and 45 minutes. 2. 05/04/24 RN did not work any hours. 3. 05/10/24 RN hours worked were 7 hours and 36 minutes. 4. 05/13/24 RN hours worked were 7 hours and 18 minutes. B. On 05/22/24 at 3:18 PM, during an interview the administrator confirmed that a RN did not work on 05/04/24. The Administrator also confirmed that the facility did not have an RN for 8 hours on 04/26/24, 05/10/24, and 05/13/24.
- Potential for harm · Fcited before2024-05-22 · 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 record review and interview, the facility failed to document the temperature of the walk-in refrigerator and walk-in freezer. This failure could potentially affect all 25 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 05/19/24). If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. Record review of the walk-in refrigerator temperature log revealed temperatures were not documented at all for the following dates: 1. 05/11/24 2. 05/12/24. 3. 05/17/24 4. 05/18/24 5. 05/19/24 B. Record review of the freezer temperature log revealed temperatures were not documented at all for the following dates: 1. 05/11/24 2. 05/12/24 3. 05/17/24 4. 05/18/24 5. 05/19/24 C. On 05/21/24 at 12:39 PM, during an interview the DM reviewed the temperature logs and confirmed that they did have missing dates indicating that the temperatures were…
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 · F2024-05-22 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility's Quality Assurance Performance Improvement (QAPI) Committee failed to establish and implement policies and procedures for feedback, data collections system, monitoring, and adverse event monitoring. This deficient practice could likely result in the facility not having opportunities for improvement, obtaining feedback from staff, the residents and the resident's representative to identify problems or concerns. The findings are: A. Record review of the Quality Assurance Performance Improvement (QAPI) Committee binder revealed, the facility do not have any policies and procedures in place. B. On 05/22/24 at 2:43 PM during an interview the Administrator confirmed did not have policy and procedures for QAPI. The Administrator stated that the facility was in the process of updating the policies and procedures for QAPI since previous policy and procedures were not working for the facility. The Administrator stated they also had new staff that needs to be retrained on the new QAPI policies and procedures.
- Potential for harm · F2024-05-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia], and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all 25 residents who live in the facility (residents were identified by the Resident Matrix provided by the Administrator on 05/19/24). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: 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 · Ecited before2024-05-22 · 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, observation, and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 6 (R #51, R #54, R #102, R #103, R #154, and R #202) of 9 (R #51, R #54, R #102, R #103, R #151, R #154, R #155, R #156, and R #202) residents reviewed for care plans when they failed to: 1. Revise the care plan with the most current resident information for R #51, R #54, R #102, R #103, and R #202. 2. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities, and includes other appropriate staff or professionals in disciplines as determined by the resident's needs) members participate in the care plan meeting for R #154. 3. Have the care plan meeting within seven days after the completion of the MDS assessment for R #154. These deficient practices could likely result in the care plan not being updated with the most…
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 · E2024-05-22 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received appropriate treatment and services to maintain or prevent a decrease in range of motion for some of the 25 residents in the facility that could benefit from therapy services or a restorative nursing program (RNP; nursing service that often follows skilled rehabilitation services provided by physical or occupational therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions) (resident were identified by the resident Census list provided by the Administrator on 05/19/24), when they failed to have a process to: 1) Evaluate residents for range of motion (ROM, the angular distance and direction a joint can move between the flexed and extended position) needs, and 2) Provide services to residents who could benefit from a RNP. These deficient practices could likely result in decreased mobility or a decrease in residents' abilities to participate or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-22 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 60 days for 3 (R #52, R #53, R #54, and R #202) of 5 (R #51, R #52, R #53, R #54, and R #202) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: R #52: A. Record review of R #52's Electronic Medical Record (EMR) revealed: 1. R #52 was admitted to the facility on [DATE]. 2. Last physician visit was on 12/17/23. R #53: B. Record review of R #53's EMR revealed: 1. R #53 was admitted to the facility on [DATE]. 2. Last physician visit was on 11/11/23. R #54: C. Record review of R #54's EMR revealed: 1. R #57 was admitted to the facility on [DATE]. 2. Last physician visit was on 12/17/23. D. On 05/22/24 at 2:20 PM, during an interview with the medical records clerks, she confirmed R #52 and R #54's last physician visit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-22 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents obtained dental services for 2 (R #102 and R #202) of 3 (R #102, R #103 and R #202) residents sampled for dental services, when they failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: A. Record review of R #102's medical record revealed an admission date of 03/08/23. B. On 05/19/24 at 2:40 PM, during an observation of R #102, R #102's dentures were floating in his mouth. When R #102 would talk, his dentures would move and not stay in place. C. On 05/20/24 at 11:47 AM, during an interview, CNA #11 said that he helps R #102 with his dentures every day, putting them in, taking them out, etc. CNA #11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-22 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #51) of 4 (R #51, R #53, R #54 and R #202) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #51 A. Record review of R #51's Skin only evaluation completed by LPN #3 on 04/19/24 revealed diabetic foot ulcer (a slow-healing wound that commonly appears on the ball of the foot due to complications of diabetes) of the left outer heel. B. Record review of R #51's physician's orders revealed, an order date 05/13/24, refer R #51 to [name of agency] wound care for in-house visits and treatment of any wounds. C. Record review of R #51's wound care consultation note dated 05/13/24 revealed, wound #1 is located to the left heel, wound #1 was at stage 2 pressure ulcer (open wound to the skin caused by pressure, that has progressed to affect both the top and bottom layers of the skin but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-22 · tag F0949 — failed to train staff on dementia and abuse — patternProvide behavior health training consistent with the requirements and as determined by a facility 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 provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 3 staff (RN #1, LPN #1, and CNA #1) of 4 (RN #1, LPN #1, CNA #1, and CNA #2) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of R #51's admission record (no date), revealed that she was admitted to the facility on [DATE] with the diagnosis of Unspecified mood (affective) disorder (condition that severely impacts mood). B. Record review of R #53's admission record (no date), revealed that she was admitted to the facility on [DATE] with the diagnosis of Schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination 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 before2024-05-22 · 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 ensure a comprehensive Minimum Data Set Assessment was completed within 14 calendar days after admission for 2 (R #151 and R #156) of 3 (R #151, R #155, and R #156) residents reviewed. This deficient practice could likely result in residents' preferences and care needs not being met. The findings are: R #151 A. Record review of R #151's admission record revealed an admission date of 04/26/24. B. Record review of R #151's medical record revealed an admission MDS assessment was in progress (assessment has been started but all sections have not been completed) on 05/22/24. C. On 05/22/24 at 10:00 AM, during an interview with the Infection Control Nurse (RN who signs off on completed MDS assessments), he confirmed the following: 1. R #151 was admitted to the facility on [DATE]. 2. R #151's admission MDS assessment was still in progress and was not completed within 14 days of admission. R #156 D. Record review of R #156's admission record revealed 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 · Dcited before2024-05-22 · 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 record review and interview, the facility failed to develop a comprehensive care plan for 1 (R #54) of 4 (R #51, R #52, R #53, and R #54) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the needs of the residents. The findings are: A. Record review of R #54's medical record revealed R #54 was admitted on [DATE]. On 05/19/24 at 3:07 PM, during an interview, R #54 stated that she has swelling to her legs and wears stockings every day to help decrease the swelling. B. Record review of R #54's physician's orders revealed: 1. Order date 07/14/21, apply TED hose (compression stockings that help prevent or decrease the occurrence of blood clots and swelling in the legs) to bilateral lower extremities (both legs) in the morning for edema (swelling caused due to excess fluid accumulation in the body tissues). 2. Order date 07/14/21, remove TED hose every day at bedtime for edema. 3. Order date 04/16/24, monitor for edema every shift for edema in bilateral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure physician's orders were entered for 1 (R #155) of 1 (R #155) residents reviewed for behavioral health. This deficient practice could likely result in resident's not receiving the appropriate medications or treatment and lead to worsening of the resident's condition. The findings are: A. On 05/20/24 at 9:34 AM, during an interview with R #155's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters), she stated the following: 1. R #155 had been depressed (a common mental disorder that involves depressed mood or loss of pleasure or interest in activities for long periods of time). 2. R #155 had not been eating or drinking very well. 3. She spoke with the facility doctor on 05/19/24 and was told that a medication would be ordered to help R #155 with depression and to increase her appetite. B. Record review of R #155's entire medical record revealed the record did not contain any orders or progress notes from the provider's visit on 05/19/24. C. On 05/20/24 at 2:15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-22 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure call lights worked and that the pull cords for the call lights in the resident's bedrooms were in reach to allow residents to call for help using the call light system, for 1 (R #207) of 3 (R #202, R #204, and R #207) residents randomly sampled for call light function. If the facility does not have a functioning call light system, then residents are unlikely to get their immediate needs met by facility staff. The findings are: A. On 05/19/24 at 3:00 PM, during an observation of R #207 bedroom, revealed the call light cord was missing. B. On 05/19/24 at 3:08 PM, during an interview with R #207, she stated, I don't have a call light (the call light cord was missing), no wonder the aides do not come. R #207 stated that she knows to press the call light cord to call for assistance. C. On 05/19/24 at 3:28 PM, during an interview with LPN #31, she confirmed R #207 did not have call light cord and stated [Name of R #207] does not use her call light.
- Potential for harm · F2023-06-15 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure that licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs. This could affect all 25 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on 06/11/23). This deficient practice could likely result in Nurses and CNA's working with residents without adequate competencies to do; so resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of the personnel files revealed no competencies for the following staff: LPN #2, RN #22, RN #23, CNA #21, CNA #22, and CNA #23. B. On 06/15/23 at 2:33 pm, during an interview, the Infection Preventionist revealed that there were no competencies on file for any of the nurses or CNA's. During an interview at that time, the Administrator confirmed that no competencies had been completed for any of the nursing staff.
- Potential for harm · Fcited before2023-06-15 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to have full-time Director of Nursing (DON). This has the potential to affect all 25 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/11/23). This deficient practice could likely result in residents not receiving the services that they need for optimal quality of care. The findings are: A. Record review of the facility's staff list revealed the facility did not have a DON (or acting DON). B. On 06/11/23 at 2:33 pm, during an interview, the Administrator confirmed that the facility did not have a DON employed at that time.
- Potential for harm · Fcited before2023-06-15 · tag F0730 — widespreadObserve 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 interview, the facility failed to provide performance reviews and specific in-service education, based on the outcome of those reviews for 3 (CNA #21, CNA #22, and CNA #23) of 3 (CNA #21, CNA #22, and CNA #23) CNA's reviewed for education. This deficient practice could likely result in CNA's not getting the training competencies needed to care for their residents, resulting injury or insufficient care to residents. The findings are: A. Record review of CNA's #21, #22, and #23 personnel files revealed no performance reviews. B. On 06/15/23 at 2:33 pm, a joint interview with the Infection Preventionist and Administrator revealed that there were no performance reviews on file for CNA #21, CNA #22, and CNA #23.
- Potential for harm · F2023-06-15 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for January 2023-March 2023. This has the potential to affect all 25 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/11/23). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility. The findings are: A. Record review of Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated, Quarter #2 2023 (January 1 - March 31) revealed: 1. Failed to Submit Data for the Quarter. B. On 06/15/23 at 2:33 PM, during an interview, the Administrator revealed that she started her employment at the facility at the end of March 2023 and could not answer as to why the PBJ was not submitted for Quarter #2.
- Potential for harm · Fcited before2023-06-15 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure 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 that 3 (CNA #21, CNA #22, and CNA #23) of 3 CNA's (CNA #21, CNA #22, and CNA #23) received their required annual training of no less than 12 hours per year. This deficient practice could likely result in CNA's not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #21: A. Record review CNA #21's online training revealed: 1. No 12 hours of in-services per year, 2. No Abuse/Neglect training, and 3. No training on identifying resident needs (behavioral health, communication) CNA #22: B. Record review of CNA #22's online training revealed: 1. No 12 hours of in-services per year, and 2. No training on identifying resident needs (behavioral health, communication) CNA #23: C. Record review of CNA #23's online training revealed: 1. No 12 hours of in-services per year, 2. No Abuse/Neglect training, 3. No Dementia training, and 4. No training on identifying resident needs (behavioral health, communication) D. On 06/15/23 at 2:33 PM, during a joint interview with the Infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-15 · tag F0636 — patternAssess 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 ensure that a comprehensive assessment was completed within 14 days of admission for 2 (R #9 and R #23) of 9 (R #3, R #5, R #7, R #9, R #15, R #17, R #18, R #19 and R #23) residents sampled for MDS (Minimum Data Set/comprehensive health) assessment. This deficient practice could likely lead to residents' needs and preferences not being met. The findings are: R #9 A. Record review of R #9's admission Record revealed she was admitted to the facility on [DATE]. B. Record review of R #9's MDS assessment revealed Signature of RN Assessment Coordinator verifying assessment completion signed on 02/13/23. R #23 C. Record review of R #23's admission Record revealed she was admitted to the facility on [DATE]. D. Record review of R #23's MDS assessment revealed Signature of RN Assessment Coordinator verifying assessment completion signed on 02/22/23. E. On 06/15/23 at 2:32 PM, during an interview, the ADON stated that the facility was aware of the situation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-15 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure that 4 (R #3, R #5, R #7, and R #9) of 9 (R #3, R #5, R #7, R #9, R #15, R #17, R #18, R #19 and R #23) residents reviewed for Resident Assessments had MDS (Minimum Data Set; Comprehensive Assessment) transmitted (sent electronically and accepted into the CMS [Centers for Medicare and Medicaid services] system) within 14 days of completion. This deficient practice could likely lead to residents receiving less than optimal care. The findings are: R #3 A. Record review of R #3's Quarterly MDS revealed the assessment was completed on 04/24/23. B. On 06/15/23 during a record review of R #3's MDS assessments, it revealed the Quarterly MDS assessment had not been transmitted. R #5 C. Record review of R #5's Quarterly MDS revealed the assessment was completed on 05/02/23. D. On 06/15/23 during a record review of R #5's MDS assessments, it revealed the Quarterly MDS assessment had not been transmitted. R #7 E. Record review of R #7's Quarterly MDS revealed the assessment was completed on 05/09/23. F. On 06/13/23 during 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 · E2023-06-15 · 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, interview, and record review, the facility failed to provide respiratory care (health care discipline specializing in the promotion of optimum cardiopulmonary function, health and wellness) that was consistent with professional standards of practice for 1 (R #6) of 1 (R #6) resident sampled for respiratory care when they failed to change R #6's nasal cannula (medical device to provide supplemental oxygen therapy to through the nose) within 7 days of the previous change. This deficient practice could likely cause the nasal cannula to become obstructed, non-functional, and unsanitary and not provide the resident with the oxygen needed. The findings are: A. Record review of R #6's Physicians Orders dated 04/19/23 revealed Oxygen gas; 4 Liters. Amount to administer 4 Liters/minute (L/m)via nasal cannula continuous for COPD (Chronic Obstructive Pulmonary Disease: airflow blockage and breathing-related problems) . B. Record review of R #6's Care Plan dated 04/15/23 revealed Impaired Gas Exchange Chronic Obstructive Pulmonary Disease (COPD) . Administer oxygen as…
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 · E2023-06-15 · tag F0745 — failed to provide medically-related social services — patternProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that medically-related social services were provided for 1 (R #3) of 3 (R #3, R #5 and R #127) residents reviewed for behavioral/emotional health. This deficient practice could likely lead to residents not attaining, or maintaining, their highest practicable mental and psychosocial well-being. The findings are: A. On 06/12/23 at 12:50 pm, during an interview, R #3 stated that she gets sad because no one visits with her and even other residents just walk by my room .it hurts to be here and not have anyone. B. Record review of R #3's admission Record (no date) revealed the diagnosis of Schizoaffective disorder, bipolar type (mental health disorder that can include hallucinations or delusions with periods of heightened emotion, ranging from joy to rage) and Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). C. Record review of R #3's Electronic Medical Record (EMR) revealed that she receives behavioral health services for medication management from the local health services…
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 · E2023-06-15 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure that psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) were prescribed for specific diagnoses for 1 (R #7) of 1 (R #7) resident sampled for unnecessary medications, when they failed to use an approved diagnosis for use of psychotropic medication. This deficient practice could likely result in residents receiving improper medications. The findings are: A. Record review of physician orders for R #7 dated 05/03/23 revealed: 1. RisperDAL Tablet 0.5 MG (risperiDONE) [used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder] Give 1 tablet by mouth in the evening for Behavior Management related to Unspecified Mood [Affective] Disorder. 2. Black box warning (required by the FDA for certain medications that carry serious safety risks) states, Increased mortality (the state of being subject to death) in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-15 · 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 properly store medication in the medication cart for 1 (R #13) of 8 (R #4, R #8, R #9, R #11, R #12, R#13, R #17 and R #126) residents reviewed during medication pass when the facility failed to ensure R #13's medication was not expired. This deficient practice could result in residents receiving medication that is ineffective. The findings are: A. On 06/14/23 at 2:35 pm, during an observation of the medication cart, R #13's Polymyxin B (antibiotic used to treat infection) drops were opened on 03/01/23 and expired on 05/01/23. B. On 06/14/23 at 2:36 pm, during an interview, RN #1 confirmed that R #13's Polymixin B drops were expired but, were still being used because it is only being used for R #13's feet. C. On 06/15/23 at 2:42 PM, during an interview, the ADON confirmed that expired medications should be removed from the medication carts upon expiration.
- Potential for harm · Ecited before2023-06-15 · 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 store and serve food under sanitary conditions in accordance with professional standards of food service safety. This could affect all 25 residents in the facility who eat food prepared in the kitchen (residents were identified Resident Matrix provided by the Administrator on 06/11/23), when they failed to: 1. Ensure food items in the dry pantry were labeled and dated, 2. Perform hand hygiene, 3. Handle resident's plates in a sanitary manner, 4. Ensure boxes were off the floor. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 06/11/23 at 10:29 am, during an observation of the kitchen's dry pantry revealed the following: 1. 2 packs of crackers with no open date or expiration dates 2. 1 pack of goldfish crackers with no open date or expiration date 3. Salad dressing with no open date or expiration date 4. 6…
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 before2023-06-15 · 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 a Baseline Care Plan (a plan that includes the instructions needed to provide effective and person-centered care upon admission) within 48 hours of admission for 1 (R #126) of 1 (R #126) resident sampled for Baseline Care Plans. This deficient practice could likely result in the resident not receiving the appropriate care and services and may place the resident at risk of harm. The findings are: A. Record review of R #126's admission Record revealed that R #126 was admitted on [DATE] and had the following principal diagnosis: Displaced fracture (bone broken into two or more parts) of fifth metatarsal (bone on the base of the small toe). R #126's admission record also included diagnosis of Major Depressive Disorder, Recurrent (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). B. Record review of R #126's Physician's orders revealed: Order date 06/08/23 Citalopram (medication to treat…
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 before2023-06-15 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure documents in resident records were complete for 1 (R #77) of 2 (R #77 and R #126) residents reviewed for advanced directives (legal document in which a person specifies what actions should be taken for their health when they are no longer able to make decisions for themselves, due to illness or incapacity). This deficient practice could likely result in staff not knowing a resident's medical intervention wishes and could result in delay of care, or going against a resident's wishes. The findings are: A. Record review of R #77's Medical Records revealed: 1. admission date of 05/31/23 2. Advance Directive form dated 05/31/23 revealed the Signature of Authorized Health Provider was blank. B. On 06/15/23 at 2:33 PM, during an interview, the Administrator confirmed that a physician still needs to sign R #77's Advance Directive.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MESCALERO APACHE TRIBE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 12/01/2003 |
| ESQUIBEL, CAROL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/29/2020 |
| CERVANTES, NELVA | Individual | CORPORATE OFFICER | — | since 06/29/2020 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NM
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Mexico Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 325116. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-19, 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.