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Coronado Care Center

1604 West 18th Street, Portales, NM 88130 · For profit - Limited Liability company · 80 certified beds · (575) 359-4719 Medicare & Medicaid certified

Call the home — (575) 359-4719 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Jun 2025
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 26% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
304 S Main Ave · (575) 201-9985 · Call to confirm hours
Pharmacy
501 W 18th St · (575) 359-7500 · Call to confirm hours
Grocery
501 W 18th St · (575) 356-4036 · Call to confirm hours
Park
210-298 S Avenue K · (575) 356-6662 · Typically dawn to dusk
Place of worship
1101 W 18th St · (575) 356-4273

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 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.0%11.3%15.4%better
Long-stay residents who lose too much weight2.3%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%0.9%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.5%2.0%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened5.2%11.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.1%14.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.7%95.3%typical
Long-stay residents with pressure ulcers4.2%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control27.5%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.4%14.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.3%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine96.9%86.4%79.4%better
Short-stay residents rehospitalized after admission21.0%22.0%22.6%typical
Short-stay residents with an outpatient ER visit19.0%15.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.041.651.67better
Long-stay outpatient ER visits per 1,000 resident days2.472.811.80worse

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.

48.3% 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 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.3%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
85.1%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 85.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.3%CMS range 39.4–58.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 8.5–19.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge85.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge80.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge83.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.6–13.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.44
RN hours/ resident / day
0.52
LPN hours/ resident / day
2.53
Aide hours/ resident / day
3.50
Total nurse hours/ resident / day
0.41
RN hoursweekends
37.1%
Total nursing turnover
61.5%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 72.7 residents a day — about 91% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.71 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.45 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2025-06-13)
7
at the previous standard inspection (2024-05-17)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Fcited before2025-06-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items stored in facility's freezer were labeled and dated. This deficient practice is likely to affect 76 residents listed on the resident census list provided by the Administrator on 06/09/25 and could likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 06/09/25 at 11:03 am during observation of the facility's walk in freezer the following items were found open and undated: 1. Two bags of what appeared to be hash browns. 2. Two bags of what appeared to be French fries. B. On 06/09/25 at 11:05 am during an interview with the Dietary Manager (DM), he confirmed the items were not labeled and dated. DM stated that doesn't meet his expectations and everything in the fridge/freezer should be labeled and dated.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-13 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 5 (R #2, R #23, R #54, R #56 and R #75) of 5 (R #2, R #23, R #54, R #56 and R #75) residents reviewed when staff failed to: 1. Update R #2's care plan to include the use of a trapeze bar (a short horizontal bar that is suspended from two ropes) for mobility. 2. Update R #23's and R #54's plan of care to include hospice (care and services for people nearing the end of life). 3. Update R #56's care plan to remove the use of a communication board (a tool used to help people with limited language skills or who are nonverbal to communicate) with word cards. 4. Update R #75's plan of care to include advanced directive. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #2 A. On 06/10/25 at 1:46 pm, an observation of R #2's room revealed a trapeze bar at the head of R #2's bed. B. Record review of R #2's face…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-13 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed 3 medication errors out of 29 opportunities for 3 (R #39, R #43, R #76) of 4 (R #36, R #39, R #43, R #76) residents reviewed during medication administration. This resulted in a medication error rate of 10.34%. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 06/12/25 at 9:40 am, during an observation of Certified Medication Aide (CMA) #1 revealed the following: 1. CMA #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #76. 2. CMA #1 then failed to sanitize her hands before beginning her medication pass for R #39. 3. CMA #1 then failed to put gloves on (don) gloves to open a capsule for R #43. B. On 06/12/25 at 10:15 am during an interview with CMA #1, she confirmed she should have sanitized her hands before beginning the medication pass for R #39. She confirmed she should have…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-13 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are: R #22 A. On 06/12/25 at 10:34 am during an observation of R #22's room revealed R #22 was asleep in her recliner. The call light laid on top of the bed where she could not reach it. B. On 06/12/25 at 10:36 am during an interview with Hospice Nurse (HN) #1, she confirmed the call light was not within R #22's reach and the call light should have been. R #56 C. On 06/11/25 at 8:58 am during an observation of R #56's room, revealed R #56 was asleep in his recliner. The call light laid on top of the bed where he could not reach it. D. On 06/11/25 at 9:05 am during an interview with Certified Nurse Assistant (CNA) #2, she confirmed the call light was not within R 56's reach and the call light should have…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-13 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the hallway was accessible for residents. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 06/09/25 at 8:10 am a random observation of the [NAME] Wing revealed the following: 1. A medication cart on the right side of the hallway near room [ROOM NUMBER]. 2. A shower chair on the left side of the hallway near room [ROOM NUMBER]. B. On 06/09/25 at 8:18 am during an interview with the Restorative Nursing Aide (RNA), she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway, so residents had a clear path. C. On 06/10/25 at 8:46 am a random observation of South Wing revealed the following: 1. A medication cart on the right side of the hallway near room [ROOM NUMBER]. 2. A medication cart on the left side of the hallway…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #48) of 1 (R #48) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE]. B. Record review of R #48's physician orders dated [DATE] revealed R #48 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status. C. Record review of R #48's care plan dated [DATE] revealed R #48 was a DNR for her advanced directive code status. D. Record review of R #48's EHR revealed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 keep residents free from physical restraints for 1 (R #8) of 1 (R #8) resident observed during random observations. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's (a progressive brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out even the simplest tasks), 2. Dementia (a general term for a decline in mental ability severe enough to interfere with daily life), 3. Depression (persistent feeling of sadness, loss of interest in activities, and changes in appetite, sleep, and energy levels), 4. Cognitive communication deficit (a communication problem stemming from impairments in thinking skills, rather…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · tag F0637 — isolated
    Assess 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 and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #23) of 1 (R #23) resident reviewed for MDS assessment timing. 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 #23's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Cerebral aneurysm (a weak spot on an artery in the brain that fills with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to maintain proper infection prevention practices for 3 (R #39, R #43, and R #76) of 4 (R #36, R #39, R #43, and R #76) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 06/12/25 at 9:40 am, during an observation of Certified Medication Aide (CMA) #1 revealed the following: 1. CMA #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #76. 2. CMA #1 then failed to sanitize her hands before beginning her medication pass for R #39. 3. CMA #1 then failed to put gloves on (don) gloves to open a capsule for R #43. B. On 06/12/25 at 10:15 am, during an interview with CMA#1, she confirmed she should have sanitized her hands before beginning the medication pass for R #39. She confirmed she should have sanitized all vital sign equipment before taking R #76's vitals and in between each resident afterwards. She confirmed she should have donned (put on gloves) her gloves before she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-17 · tag F0728 — failed to protect against nurse-aide misconduct — widespread
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide documentation confirming one Nurse Aide (NA), employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 68 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: A. Record review of NA #1's personnel record revealed the following: - The NA's hire date was 12/01/23; - The record did not contain a Certified Nursing Assistant (CNA) License. - NA #1 was employed full time as of 05/17/24. - NA #1 completed the CNA training but did not complete the CNA state licensure exam. B. On 05/17/24, at 10:40 AM, during an interview with the Director of Nursing (DON), she stated NA #1 did not obtain her CNA license within four months of her hire date. The DON stated the NA completed the training but did 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Fcited before2024-05-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the dry storage area were stored properly. 2. Ensure all food items in the walk-in refrigerator were labeled and dated. 3. Ensure all food items in the freezer were sealed appropriately. This deficient practice is likely to affect all 75 residents identified on the resident census list provided by the Director of Nursing on 05/13/2024. These deficient practices are likely to expose residents to food borne illnesses. The findings are: Dry Storage Area: A. Observation on 05/13/2024 at 12:35 pm, during initial observation of the facility's food storage area, revealed one case of a 10 pound box of grape juice stored on the bare floor. B. On 05/13/24 at 12:51 pm during an interview with the Dietary Manager (DM), he confirmed the items were on the bare floor. The DM stated there should not be any boxes on the bare floor, and all items should be stored on the shelves. The DM further stated that…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and observation, the facility failed to: 1. Ensure the facility had enough food to serve all residents the meal on the menu. 2. Ensure staff served residents a second portion of meal if requested. This deficient practice is likely to affect all residents who eat at the facility. If the facility fails to provide adequate food to meet the nutritional needs of the residents then residents are likely to lose weight and not get their nutritional needs met. The findings are: Ensure the facility had enough food to serve all residents the meal on the menu. A. Record review of Residents Council minutes, dated May 2024, revealed the residents discussed the Dietary Department ran out of food and coffee often. B. On 05/13/24 at 5:49 pm, during a dining observation, revealed staff served some of the residents meals without the vegetables. Further observation revealed the facility ran out of vegetables for the meal. C. On 05/13/24 at 5:50 during an interview, Certified Nurse Aide (CNA) #2 stated the facility ran out of vegetables for the dinner meal, so some residents did 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #13) of 1 (R #13) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents. The findings are: A. Record review of R #13's most recent PASRR, dated 12/27/21, revealed the following: - Individual information: Staff documented schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) as a pertinent diagnoses. - Identification of mental illness (MI) evaluation criteria: Staff documented No, the resident did not have a diagnosis or suspected mental illness in Section C1. The criteria listed schizophrenia as a MI, but staff did not enter the diagnosis of schizophrenia. B. Record review of R # 13's Minimum Data Set (MDS; a federally mandated assessment instrument completed by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were invited to attend care plan meetings for 2 (R #23 and R #30) of 2 (R #23 and R #30) residents reviewed for participation in care planning. If residents are not able to participate in their care plan development, then residents could likely not get the care and treatment they want or need. The findings are: R #23 A. Record review of R #23's face sheet revealed R #23 was admitted into the facility on [DATE]. B. On 05/13/24 at 4:18 pm, during an interview with R #23, she stated she did not attend the last care plan meeting that was scheduled. R #23 stated it was important to her to attend her own meetings. She stated she previously talked with the Social Services Director (SSD) and explained to her that she wanted to be involved in her care and her meetings. C. Record review of R #23's Care Plan Conference (a document the facility uses to record details of a care plan meeting including attendees), dated 04/24/24, revealed R #23 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 a resident who was admitted with an indwelling Foley (name of device) catheter (a thin, sterile tube inserted into the bladder to drain urine) was assessed for the removal of the catheter for 1 (R #46) of 1 (R #46) sampled residents with an indwelling urinary catheter. This failed practice is likely to cause R #46 to not regain bladder control, to develop bladder incontinence, or to develop a bladder infection. The findings are: A. Record review of R #46's face sheet revealed the resident was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of the sacral region (the portion of the spine between the lower back and the tailbone), Stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone). B. Record review of R #46's wound reports, dated April and May 2024, revealed R #46's pressure injury was stable (had not changed since admission on [DATE].) C. Record review of R #46's physician orders…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide an adaptive eating device (a tool that helped a person with a disability do a certain task) for 1 (R #35) of 1 (R #35) residents reviewed during dining observation. If residents are not provided adaptive eating devices as needed, then residents might be unable to consume their meals and beverages and likely to have weight loss, malnutrition, and dehydration. The findings are: A. Record review of R #35's Physician's orders, dated 05/13/24, revealed the resident was to use a plate guard for meals as tolerated for improved self-feeding skills. B. Record review of R #35's meal ticket, dated 05/13/24, revealed it did not direct staff to provide adaptive feeding equipment for the resident. C. On 05/13/24 at 5:09 pm during a dining observation, R #35 ate her meal without an adaptive eating device. At 5:36 pm, Certified Nursing Assistant (CNA) #2 put a plate guard (a curved piece of material that fits around the rim of a plate to prevent food from falling off) on R #35's plate. D. On 05/13/24 at 5:40 pm, CNA…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-05-16 · tag F0656 — failed to write and follow a full care plan — widespread
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to 1) Develop a comprehensive care plan and 2) Implement a comprehensive care plan for 4 (R #2, 30, 31 and 41) of 4 (R #2, 30, 31 and 41) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being. the findings are: Findings for R #2 A. Record review of facility face sheet for R #2 admitted on [DATE] revealed admission diagnoses which included: Heart Disease (conditions that affect the heart's function and blood flow), Kidney Failure (kidneys no longer function well on their own), Reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), Obesity (overweight), Hernia (organ or tissue bulges through a weak spot in the abdominal wall), Vitamin D Deficiency (low vitamin D levels), Fracture (bone break), Muscle Atrophy (loss or thinning of muscle), Dependence On Wheelchair, Hypothyroidism (low thyroid levels),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-05-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to store food under sanitary conditions by not ensuring (1) Food items stored in facilities dry storage were labeled and dated, (2) Food items in the dry storage area were stored in the correct locations, and (3) expired foods were either used or discarded prior to expiration date. These deficient practices are likely to affect all 61 residents residing in the facility, and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 05/08/23 at 9:55 am during the initial tour of the facility kitchen the following was observed: 1. Two- 1.5 gallon Tupperware container of cereal was labeled use by 03/02/23 and was still on the shelf. 2. One- 1.5 gallon Tupperware container of cereal was labeled use by 05/02/23 and was still on the shelf. 3. One large metal mixing bowl with a powdery substance was wrapped in plastic wrap, unlabeled and stored on the shelf. 4. One undated package of gelatin was wrapped in plastic…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain a safe and comfortable homelike environment in the dining area. This failure has the potential to affect the 54 residents that choose to eat in the main dining facility. The findings are: A. On 05/08/23 at 12:12 pm during lunch observation in the dining area the following was revealed: 1. The food arrived in the dining area 15 minutes later than the scheduled lunch start time of 12:00 pm. 2. The dining area was very crowded with residents, wheelchairs and walkers making moving around difficult to include entering the dining area, serving and assisting the residents with dining, and exiting the area after the meal was complete. 3. The overcrowding of the area caused high sound levels which made any conversation difficult as it was hard to hear another person. This also caused it to be difficult to get staff attention for assistance. 4. One of the two access doors was blocked by the serving carts and staff making any egress impossible. B. On 05/08/23 at 12:45 pm during an interview with the Corporate Dietary Director,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-16 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure adequate pain relief for 1 (R #41) of 1 (R #41) resident reviewed for pain. This failure could likely result in unrelieved pain and diminished quality of life for the resident. The findings are: A. On 05/09/23 at 12:45 pm while observing R #41 during a conversation with Licensed Practical Nurse (LPN) #1, as he was exiting the dining room, it was noted that R #41 stopped his motorized wheelchair, was bending forward, and grimacing between words while speaking to LPN #1. (Using a [NAME] faces pain scale allows medical personnel to visually assess pain with zero 0 being no pain, and ten 10 being the worst imaginable). R #41 appeared to be in discomfort, and had to stop and rest while talking. LPN #1 was asking R #41 if he needed anything at the moment. R # 41 was unable to speak more that a couple of words at a time. LPN #1 stated she, would meet him at his room and see what he could have. B. Record review of R #41's care plan dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-16 · tag F0742 — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure that the mental health needs of 1 [R #31] of 1 [R #31] resident reviewed for mental health needs was assessed and care was offered/provided to ensure their highest practicable well being. This deficient practice is likely to negatively impact the health and well being of residents. The findings are: A. Record review of current facility face sheet for R #31 revealed admitting diagnosis which included: Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Muscle Weakness, Hypothyroidism (low hormone), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Bipolar Disorder (mood swings), Major Depressive Disorder (feeling of sadness), Anxiety Disorder (feeling of fear), Post-Traumatic Stress Disorder (disorder caused by trauma), Mild Cognitive Impairment (memory loss), Polyneuropathy (nerve pain), Hypertension (High Blood Pressure), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastritis (intestinal swelling), Radiculopathy,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-16 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview the facility failed to provide meals that tasted good, and served at an appetizing temperature (at or above 135 degrees Fahrenheit) for 2 (R #38 and R #164) of 2 (R #38 and R #164) residents reviewed for food quality. This failed practice has the potential to affect all residents identified on the resident census list provided by the administrator on 05/12/23 that were able to eat meals from the kitchen. This deficient practice has the potential for residents to not want to eat meals, which could lead to significant weight loss and not meeting their highest level of well-being. The findings are: A. Record review of facility meal times revealed the following: 1. Breakfast - 7:00 am 2. Lunch - 12:00 pm 3. Supper - 5:00 pm B. On 05/08/23 at 2:32 pm, during an interview R #38 stated that the food had bad flavor and was tough, and that the facility was not posting a menu for them to see what was being served. C. On 05/08/23 at 3:11 pm during an interview with R #164, he stated that the meat (hamburger patty with mushroom sauce) tasted…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility had the responsibility to implement standard precautions (infection control practice to limit or eliminate the spread of infections). The facility failed to investigate, recognize, prevent, and maintain control of the spread of infection to (24 of 61) residents. Failure to adhere to an infection control program is likely to cause the spread of infections to and from residents within the facility. The findings are: A. On 05/08/23 at 11:15 am, during an observation of the [NAME] Hall shower area the following was revealed: 1. The [NAME] shower room contained a large spray bottle with a yellowish tan liquid hanging from the hand rail. 2. There was a jar of white, thick cream that had visible finger marks in it. 3. The hallway curtain, surrounding the outside of the shower door, revealed it had some brown smudges which looked like stool had dried on the shower curtain in several places. 4. There was a trash can full of soiled incontinent briefs stacked…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-16 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure that residents have the ability to directly contact caregivers from their rooms/toilet areas from a communication system for 5 (R #36, 41, 49, and 50, and 55) of 5 (R #36, 41, 49, and 50, and 55 ) residents reviewed for an equipped call light system. If the facility is not ensuring that residents have access to request assistance from their room or bathrooms, then residents may not get the care and services they need. The findings are: A. Record review of facility Communication - Call System policy dated 10/24/22 revealed the following: Purpose:To provide a mechanism for residents to promptly communicate with nursing staff. Policy I. The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. Procedure . II. Call cords will be placed within the resident's reach in the resident's room. VIII. An adaptive call bell (e.g. flat pad call cord, hand bell, etc.) will be provided to a resident per the resident's needs. R #36 A. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-16 · tag F0920 — pattern
    Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide sufficient space for Dining. This failure has the potential to affect the all residents (as listed on the Resident Census provided by the Administrator on 05/08/23) living in the facility, and is likely to hinder safe movements, timely delivery of meals, and exceed acceptable noise levels while in the dining area. The findings are: A. On 05/08/23 at 12:12 pm, during the lunch dining the following observations were made: 1. The dining area was very crowded with residents wheelchairs and walkers, making moving around difficult to include entering the dining area, serving and assisting the residents with dining, and exiting the area after the meal was complete. 2. The overcrowding of the area caused high sound levels which made any conversation difficult as it was hard to hear another person. This caused it to be difficult to get staff attention for assistance. B. On 05/09/23 at 12:26 pm, during the lunch dining the following observations were made: 1. The dining area was crowded with residents. 2. Their talking caused…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to timely revise and update a care plan for 1 (R #49) of 2 (R #31 and R #49) residents reviewed for pain. This deficient practice could likely cause staff to be unaware of current resident needs and impair the safety of residents. The findings are: A. Record review of current facility face sheet dated 05/01/22 for R #49 revealed admitting diagnosis which included: Pain In Left Hand, Pain In Left Wrist, Mood [Affective] Disorder (mood swings), Anxiety Disorder (feeling of fear), Chronic Pain (constant pain), Hypertension (high blood pressure), Dorsalgia (back pain), Benign Prostatic Hyperplasia (difficulty urinating), Abdominal Pain, Weakness, Intracranial Injury With Loss Of Consciousness Of Unspecified Duration (brain injury), Personal History Of Covid-19 (viral lung infection), Dementia (memory loss), and Need For Assistance With Personal Care. B. Record review of pain care plan dated 04/14/23 for R #49 revealed an approach of: Encourage The Resident To: Call For Assistance When In Pain, Reposition Self, Ask…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-16 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview the facility failed to provide trauma informed care (care to help prevent furtherance of trauma and promote safety and well-being) to 1 (R #31) of 1 (R #31) resident diagnosed with a trauma incident. Failing to provide care and seek out knowledge of triggers is likely to cause the resident to become secluded (withdrawn), exhibit behaviors, or cause self harm. The findings are: A. Record review of current facility face sheet for R #31 revealed admitting diagnosis which included: Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Muscle Weakness, Hypothyroidism (low hormone), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Bipolar Disorder (mood swings), Major Depressive Disorder (feeling of sadness), Anxiety Disorder (feeling of fear), Post-Traumatic Stress Disorder (disorder caused by trauma), Mild Cognitive Impairment (memory loss), Polyneuropathy (nerve pain), Hypertension (High Blood Pressure), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure that pharmaceutical services for 1 (R #48) of 1 (R #48) resident reviewed for accurate dispensing and administration was correct. The pharmacy placed multiple orders for the medication on the same package creating confusion. This failure could cause a potential overdose of R # 48. The findings are: A. On 05/10/23 at 7:45 pm during an observation of R #48 during receipt of medication from License Practical Nurse (LPN) #2, two (2) blister packs (flat cardboard with medication attached with a plastic cover) for R #48 did not match the physician orders for May 1- May 31 on the MAR, (the label which directs the nurse what to give). On the blister packs, the following doses were listed: 1. Carbidopa/Levodopa (this medication is used to treat symptoms of Parkinson's disease such as shakiness, stiffness, difficulty moving) the tablets contain a combination of carbidopa 25 mg and levodopa 100 mg. The order on the blister pack stated, One (1) tablet every day at bedtime 2. Carbidopa/Levodopa 25/100 the order on the same blister…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to OPCO SKILLED MANAGEMENT — 66 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.3+1.7 vs chain
Health inspection 4 of 52.2+1.8 vs chain
Staffing 3 of 51.7+1.3 vs chain
Quality measures 3 of 54.3-1.3 vs chain
The other 65 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Bluebird Wellness And RehabilitationSaint Louis, MO 1 of 5Brentwood Place ThreeDallas, TX 1 of 5Broadway Nursing & RehabilitationSan Antonio, TX 1 of 5Cameron Nursing CenterCameron, MO 1 of 5Carmel Hills Wellness & RehabilitationIndependence, MO 1 of 5Casa Arena Healthcare LLCAlamogordo, NM 1 of 5Casa Maria HealthcareRoswell, NM 1 of 5Forest Park Nursing & RehabilitationDallas, TX 1 of 5Fort Worth Wellness & RehabilitationFort Worth, TX 1 of 5Glenview Wellness & RehabilitationNorth Richland Hills, TX 1 of 5Highland Pines Nursing HomeLongview, TX 1 of 5Ivy Creek Wellness & RehabilitationWaco, TX 1 of 5Las Cruces Village Nursing & Rehabilitation LLCLas Cruces, NM 1 of 5Magnolia Wellness CenterSaint Louis, MO 1 of 5Maple Grove Wellness & RehabilitationFenton, MO 1 of 5Mineola Gardens Wellness & RehabilitationMineola, TX 1 of 5Pine Grove ManorSaint Louis, MO 1 of 5Rehab Of Kansas City SouthKansas City, MO 1 of 5The Hillcrest Of North DallasDallas, TX 1 of 5West Side Campus Of CareWhite Settlement, TX 1 of 5Willow Ridge Wellness & RehabilitationFort Worth, TX 1 of 5Willowcreek Wellness & RehabilitationFlorissant, MO 2 of 5Arbor Lake Nursing & Rehabilitation, LLCFort Worth, TX 2 of 5Aztec HealthcareAztec, NM 2 of 5Betty Dare Wellness & Rehabilitation LLCAlamogordo, NM 2 of 5Blue Springs Wellness & RehabilitationBlue Springs, MO 2 of 5Cypress Springs Wellness & RehabilitationMount Vernon, TX 2 of 5Fiesta Park Wellness & RehabilitationAlbuquerque, NM 2 of 5Hilltop At Blue River, TheKansas City, MO 2 of 5La Vida Buena HealthcareLas Vegas, NM 2 of 5Los Alamos Wellness & RehabilitationLos Alamos, NM 2 of 5McGregor Wellness & RehabilitationMc Gregor, TX 2 of 5Monarch Springs Wellness & RehabilitationUniversity City, MO 2 of 5Northrise Wellness & RehabilitationLas Cruces, NM 2 of 5Prescott Valley Nursing & RehabilitationPrescott Valley, AZ 2 of 5Prescott Village Nursing & RehabilitationPrescott, AZ 2 of 5Rehabilitation Center Of Independence, TheIndependence, MO 2 of 5San Antonio Wellness & RehabilitationSan Antonio, TX 2 of 5Skyline Nursing CenterDallas, TX 2 of 5Sunny Springs Nursing & RehabSulphur Springs, TX

Showing 40 of 65; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
CASA HEALTHCARE, LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
CALIBER ADVISORS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2023
FIRST SWEETZER HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2023
HATTERAS INVESTMENTS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2023
GARETZ, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
FOSTER, JALAINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/16/2025
GURWITZ, SOLOMONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/17/2025
HAGINS, ELIZABETHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/17/2025
KAPLAN, ESTHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/17/2025
KAPLAN, MOSHAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/17/2025
MINDLE, ADAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/17/2025
STERNSHEIN, JENNIFERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/01/2025
UNGER, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/17/2025
ZIMMERMAN, CAROLINEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/01/2025
1604 W 18TH STREET NM, LLCOrganizationADP OF THE SNFsince 03/01/2023
CONTINUUM REHAB GROUP LLCOrganizationADP OF THE SNFsince 03/01/2023
HALLMARK ADVISORS, LLCOrganizationADP OF THE SNFsince 03/01/2023
HANSEN HUNTER LLCOrganizationADP OF THE SNFsince 07/17/2025
OPCO CA SKILLED MGMT INC.OrganizationADP OF THE SNFsince 03/01/2023
OPCO NM SKILLED MGMT, LLCOrganizationADP OF THE SNFsince 03/01/2023
THE WRIGHT GROUP CONSULTING, LLCOrganizationADP OF THE SNFsince 04/01/2024
WILSHIRE HEALTH REALTY, LLCOrganizationADP OF THE SNFsince 03/01/2023
STOLARCZYK, LISAIndividualADP OF THE SNFsince 03/07/2024

CMS files one row per role, so the 26 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

12 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.7M
Net patient revenuemost recent cost report
-4.9%
Operating marginrevenue minus expenses
$2.7M
Related-party expense26% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 13%Other / private 12%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$397per resident / day
operating cost
$12,058per month
≈ monthly operating cost
$378per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NM

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Mexico Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 325114. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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