Colfax General LTC
615 Prospect Avenue, Springer, NM 87747 · For profit - Partnership · 33 certified beds · (575) 483-3300 Medicaid only — no Medicare
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (68%) runs well above the national median (45%)
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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 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.
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 | 17.4% | 11.3% | 15.4% | worse |
| 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 | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 6.0% | 0.9% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.9% | 2.0% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 6.9% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.8% | 11.7% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 14.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 91.2% | 98.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 5.2% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 18.1% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.2% | 14.5% | 17.1% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 1.65 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 4.38 | 2.81 | 1.80 | worse |
* 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.
Staffing
How full it usually is: this home is certified for 33 beds and averages 30.5 residents a day — about 92% occupied, or roughly 2 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 2.60 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.12 hrs/resident/day on weekends vs 2.80 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.83 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.
- Actual harm · G2023-02-28 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 record review, observation, and interview, the facility failed to ensure that 1 (R #30) of 1 (R #30) resident reviewed was receiving the necessary behavioral health care services to meet the residents needs. This deficient practice likely resulted in resident not getting the care and assistance he needed, resulting in R #30 assaulting a staff member and being transferred to jail. The findings are: A. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE] with the following psychiatric diagnoses: 1. MAJOR DEPRESSIVE DISORDER 2. BORDERLINE PERSONALITY DISORDER 3. MILD COGNITIVE IMPAIRMENT (the stage between the expected decline in memory and thinking that happens with age) B. Record review of care plan date (OVERDUE) revealed the following: 1. Focus: The resident uses antidepressant medication r/t (related to) Depression. Interventions: Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition;…
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 before2025-04-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food was stored appropriately and not left open to air in the kitchen freezer. These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 04/21/25 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 04/21/25 at 1:03 pm, observation of the kitchen revealed the following: - 3 pecan pies, 3 apple pies, 1 sheet cake, and 1 box of salmon fish fillets were not labeled or dated and stored in the kitchen freezer. - 1 package of pepperoni, 1 pack of chicken nuggets, and 1 box of salmon fish fillets were open to air and stored in the kitchen freezer. - 1 box of eggs was sealed but was not labeled or dated in the kitchen refrigerator. - 2, 12 pack soda cases were stored on the floor in the dry…
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 · E2025-04-23 · 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 interview, the facility failed to meet professional standards for 3 (R # 5, 6, and 7) of 9 (R #1, 5, 6, 7, 8, 9, 10, 11, and 12) residents when staff failed to: 1. Ensure R #5's, R #6's, and R #7's humidity (attachable bottle to moisten administered oxygen) is added to concentrator and that O2 concentrator is capable of having humidy added. 2. Label and date oxygen (O2) tubing per physician orders for R #5, R #6 and R #7. If the facility is not following physician orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's physician orders dated 02/28/25, revealed an order to change humidifiers (device used to moisten medical O2) and nasal cannulas (device used to administer medical O2) on the night shift every Friday. C. On 04/22/25 at 2:06 pm during an observation of R #5's room, R #5'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 · D2025-04-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 resident's provider of a decline in condition for 1 (R #1) of 1(R #1) resident reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider when the resident experiences a change of condition, then the provider is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: -Acute Kidney Failure (condition in which the kidneys can't filter waste from the blood). -Dementia (memory loss). -Chronic Obstructive Pulmonary Disease unspecified (shortness of breath). -Alcoholic Cirrhosis (damage of cells, swelling, and thickening of the liver). -Cerebral Vascular Accident (Stroke). -UTI (Urinary Tract Infection). B. Record review of R #1's daily care/progress notes revealed the following: - On 03/11/25, R #1 had refused to eat for a couple 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 · D2025-04-23 · 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 — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 1 (R #13) of 5 (R #2, #3, #4, #5, and #13) residents observed for call lights. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff. The findings are: A. On 04/22/25 at 9:17 am during a call light observation, R #13's call light was activated, but it did not sound at the nurse's station or the unit to alert staff of call light activation. The call light did not activate the marquee (electronic signage displaying room numbers) notification, the nurse's station visual alert or nurse's station audible alert. B. On 04/22/25 at 9:20 am during interview with Registered Nurse (RN #1), RN #1 stated call lights should alert staff at the nurses station when activated and should display on marquee in the unit halls. RN #1 confirmed R #13's call light did not alert the nursing station when activated nor display on marquee of the call light 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 · Fcited before2025-01-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Kitchen refrigerators were free from dietary staff personal food. 3. Food was stored appropriately and not left open to air in the kitchen. 4. Salad was stored on ice prior to meal service. These deficient practices are likely to affect all 32 residents listed on the resident census list provided by the Administrator on 01/27/25 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 01/27/25 at 12:39 pm, observation of the kitchen revealed the following: - One Styrofoam To-Go container labeled [Name of [NAME] 1] dated 01/27/25 was stored in the kitchen refrigerator. - Three large plastic bags of crinkle cut fries were not labeled or dated and stored in freezer #1. - One large plastic bag…
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 · F2025-01-30 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure that all garbage and refuse containers have lids or are otherwise covered in the kitchen. This deficient practice could likely affect all 32 residents identified on the resident census list provided by the Administrator on 01/27/25. This deficient practice could likely result in shelter and feeding of pests. The findings are: A. On 01/30/25 at 11:45 am, observation of the kitchen revealed the following: - One small trash can filled with trash was not covered and stored under the dishwashing station next to an open box of muffins. - One large trash can was filled with trash and not covered next to the three compartment kitchen sinks and stove. B. On 01/30/25 at 11:48 am during an interview with the Dietary Manager (DM), he confirmed both trash cans were uncovered in the kitchen near food prep areas. The DM stated all trash cans should be stored with lids.
- Potential for harm · D2025-01-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #34) of 1 (R #34) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially life saving procedures. The findings are: A. Record review of R #34's physician orders dated [DATE] revealed R #34 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. B. Record review of R #34's care plan dated [DATE] revealed R #34 was a DNR for her advanced directive code status. C. Record review of R #34's face sheet revealed R #34 was admitted into the facility on [DATE]. D. Record review of R #34'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.
- Potential for harm · D2025-01-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to report the results of an investigation regarding allegations of abuse for 2 (R #'s 8 and 22 ) of 2(R #'s 8 and 22) residents reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency (SA), then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Refer to F0610 for related findings. B. On 01/30/25 at 2:33 pm during an interview with the Administrator (ADM), she stated the incident involving R #8 and R #22 with an agency Certified Nurse Assistant (CNA) was not reported to the SA. The ADM stated that R #8 only reported experiencing issues with the agency CNAs bedside manner towards him and R #22, but the facility could not define what bedside manner meant in this case. When asked if this could be considered verbal abuse, the ADM was unsure and stated she could not rule out verbal abuse with the information that was provided to her. The ADM confirmed all allegations of abuse, including verbal…
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 · D2025-01-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thorough investigation and report the investigation findings within five working days, for an allegation of abuse for 2 (R #'s 8 and 22) of 2 (R #'s 8 and 22) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of the facility's investigation report dated 12/23/24 revealed the following: - R #8 requested to speak to the Administrator (ADM) regarding concerns of bedside manner of an agency Certified Nursing Assistant (CNA) while assisting R #22. -R #8 stated that his back was turned when the agency CNA assisted R #22, he had concerns of poor bedside manner regarding that interaction. - Multiple residents were interviewed on 12/23/24 with the residents confirming…
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 before2024-01-19 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to assure medications and other medical supplies were properly stored and not expired. This deficient practice had the potential to affect all 28 residents identified on the facility census list provided by the Director of Nursing (DON) on 01/16/24. Improperly stored medications and medical supplies could likely lead to confusion and possibly result in residents being administered expired medications and supplies. The findings are: Medication Storage Room A. Observation on 01/16/24 at 2:01 pm, during a routine check of the facility medication storage room, revealed the following: 1. One container of Clorox Bleach Germicidal wipes expired on 04/14/22, 2. One, 30 gram (g) bottle of Nystop (Nystatin) powder (an antifungal, antibiotic powder used to treat skin infections caused by yeast) expired on 05/23/22, 3. One open bag of Goodsense cough drops, menthol flavor, 30 drops, expired on 07/01/22, 4. One jar of Vicks VapoRub (an ointment to help relieve cough,…
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 9 citations
- Potential for harm · F2024-01-19 · 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 interview 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 c ourse 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 deficient practice is likely to affect all 28 residents living at the facility. Residents are likely not to receive the dietary nutritional services needed to thrive and their…
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 before2024-01-19 · 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
Based on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety. This deficient practice is likely to affect all 28 residents identified on the resident census list provided by the Director of Nursing (DON) on 01/16/24. These deficient practices are likely to expose residents to food borne illnesses. The findings are: A. Observation on 01/16/24 at 11:53 am, during initial observation of the facilities food storage area, revealed the following: Please note the following items listed below were opened. 1. One box of 20 pounds of frozen stuffed bell peppers opened and not dated. 2. One box of 20 pound (lb) beef stroganoff opened and not dated. 3. One box of sausage patties opened and not dated. B. Observation on 01/16/24 at 12:00 pm, during observation of the facilities food storage area, revealed the following: 1. One box of 24 ounce (oz), citrus gelatin opened and not dated. 2. One box of 24 oz, red assorted gelatin opened and not dated. 3. One box…
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 before2023-02-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store foods under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer are properly covered. 3. Ensuring used oil was covered appropriately, labeled, and dated in the dry storage. These deficient practices are likely to affect all 26 residents listed on the resident census list provided by the Director of Nursing (DON) on 02/17/23, and are likely to 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 02/27/23 at 9:52 am during the initial tour of facility kitchen, the following was observed in the kitchen freezers, kitchen refrigerators, and kitchen dry storage: 1. 3- plastic storage bags of rolls was not labeled or dated and stored in the refrigerator. 2. 1- baked potato wrapped in aluminum foil was not labeled or dated and stored in the refrigerator. 3. 1- 37.05 ounce (oz) Sysco Classic Golden Grill Hash…
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 · F2023-02-28 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to have a qualified, trained, or appropriately certified Infection Control Nurse designated as the Infection Preventionist (IP) affecting all 26 residents identified on the resident census list provided by the Director of Nursing (DON) on 02/27/23. This deficient practice is likely to result in residents being at greater risk of infectious disease. The findings are: A. Record review of the IP's Infection Control and Prevention Certificate of Completion- 4.0 Credit Hours dated 06/28/22 revealed the certificate was not obtained from an approved source. The certificate was issued by New York State Department of health. B. On 02/28/23 at 2:21 pm during an interview with the IP, she stated, I didn't know I needed it [Infection Control and Prevention Certificate]. Nobody ever told me about that one [approved Infection Control and Prevention Infection Preventionist Certificate]. C. On 02/28/23 at 4:50 pm during an interview with the Director of Nursing (DON), she stated, [Name of the Facility Human Resources Staff] and I just spoke…
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 before2023-02-28 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to: 1. Ensure narcotic medications (regulate medications-perception-altering or sensory-dulling medications) are properly documented after medication administration. 2. Ensure medication storage room is kept at the appropriate temperature (68-77 degrees Fahrenheit) These deficient practices are likely to negatively impact the health of all 26 residents listed on the census provided by the Director of Nursing (DON) on 02/27/23. A. On 02/28/23 at 9:15 am during review of the narcotic medication log and the medication bubble pack (medication card that holds all the medication and is numbered) it was observed that the medication Hydrocodone-APAP 5-325 (medication used to treat pain) for R #1 was documented in the log book as having 22 tablets left in the bubble pack and review of the bubble pack revealed that there were 21 tablets in the bubble pack. B. On 02/28/23 at 9:16 am during an interview with Registered Nurse (RN) #1, she stated that the medication in the bubble pack and the narcotic log book did not match. The medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-28 · tag F0851 — patternElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview the facility failed to submit accurate direct care staffing information to CMS (Centers for Medicare Services). This deficient practice is likely to result in inaccurate direct care staffing information for residents/facility. The findings are: A. On 02/28/23 at 12:40 PM during an interview with the Director of Nursing (DON) when asked if there was 24 hour licensed nursing coverage and sufficient weekend staffing due to the triggered Payroll Based Journal (PBJ) Staffing Data Report she stated yes. The inaccurate staffing totals on the PBJ Report were due to the incorrect data entry. The errors were for the Fiscal Year Quarter 4 2022, July 1 - September 30. B. On 02/28/23 at 12:50 PM during an interview with the Lab Clerk, she stated that she is the person who is responsible for entering the data for the PBJ report. She further stated that she did not know all the positions of the agency nurses if they were Registered Nurses (RN's) or Licensed Practical Nurses (LPN's) and that she was also including the dietary staff in the PBJ as part of the nursing direct 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 · D2023-02-28 · 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 ensure that 1 (R #27) of 1 (R #27) residents reviewed for Minimum Data Set (MDS) assessments, had MDS documents completed, submitted and finalized in a timely manner (after her discharge). If MDS assessments are not completed and submitted in a timely manner, then residents are likely to receive less than optimal care. The findings are: A. Record review of R #27's face sheet revealed R #27 was admitted into the facility on [DATE]. B. Record review of R #27's MDS Page located in R #27's Electronic Health Record (EHR) revealed R #27's latest completed and submitted MDS assessment was the Quarterly Review dated 10/12/22. C. On 02/28/23 at 9:49 am during an interview with the Director of Nursing (DON), confirmed R #27 was discharged from the facility on 11/15/22 and did not return . D. On 02/28/23 at 2:28 pm during an interview with the Minimum Data Set Coordinator (MDSC), she stated, I think she [R #27] went home and passed away. If I recall correctly,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-28 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that reflects anticoagulant use (medication used to prevent blood clots) for 1 (R #8) of 1 (R #8) residents reviewed. Failure to develop and implement a resident centered care plan may result in staff's inability to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. B. Record review of R #8's physician orders dated 10/12/22 revealed, Warfarin Sodium Tablet [anticioagulant] 7.5 MG [milligram]. C. Record review of R #8's Care Plan dated 01/25/23 revealed no care plan for anticoagulant use. D. On 02/28/23 at 5:30 pm during an interview with the Director of Nursing (DON), she confirmed anticoagulant use for R #8 was not care planned and should have been.
- Potential for harm · D2023-02-28 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure the attending physicians reviewed and responded to pharmacy recommendations for 6 residents [R #2, 9, 10, 12, 14, 16] of 7 residents [R #2, 8, 9, 10, 12, 14, 16] reviewed for Gradual Dose Reductions. If consultant pharmacist recommendations are not reviewed by physicians and orders are not implemented on time, residents are likely to continue taking medications they do not need, or potentially experience unnecessary drug interactions or adverse side effects. The findings for R #2: A. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations: On 05/19/22 pharmacist's recommendation for R #2 stated Please review Lorazepam [used to treat anxiety disorders] therapy for Gradual Dose Reduction (GDR). This document was not responded to or signed by the physician until 11/11/22. Findings for R #9: B. Review of documents labeled Consultation From Consultant Pharmacist To Clinical Provider revealed the following recommendations: On 05/19/22 pharmacist's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in NM
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 32E032. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.