Inspection Reports for
Casa Arena Healthcare LLC
205 MOONGLOW, ALAMOGORDO, NM, 88310
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
29.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
318% worse than New Mexico average
New Mexico average: 7.1 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
87% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted to review and document deficiencies related to the facility's maintenance of accurate and complete medical records for residents, specifically regarding wound care documentation.
Findings
The facility failed to ensure complete and accurate documentation of a resident's skin impairment and wound care assessments. The wound care nurse did not document assessments and treatments in the resident's medical record, which could negatively impact resident care.
Deficiencies (1)
Failure to document wound care assessments and treatments for resident #9's coccyx skin impairment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #8 | Interviewed regarding skin assessment and notification of medical provider. | |
| Wound Care Nurse (WCN) | Interviewed regarding wound assessment and failure to document treatments. | |
| Director of Nursing (DON) | Interviewed and confirmed documentation deficiencies by the WCN. |
Inspection Report
Routine
Census: 102
Deficiencies: 4
Date: Jul 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, assessment timing, environment cleanliness, nurse staffing information posting, and timely completion of MDS assessments.
Findings
The facility was found deficient in maintaining a clean and homelike environment, timely completion of admission and significant change MDS assessments, and posting nurse staffing data daily. Deficiencies were noted with minimal harm potential affecting few residents, and one deficiency related to nurse staffing affected many residents.
Deficiencies (4)
Failed to provide a comfortable and homelike environment by not keeping resident #8's bathroom clean of urine around the toilet.
Failed to complete a comprehensive MDS assessment within 14 calendar days after admission for resident #1.
Failed to complete and transmit a Significant Change in Condition (SCIC) MDS assessment within 14 days for resident #2 admitted to hospice.
Failed to post nurse staffing data daily for access by the public and residents, including total number and actual hours worked by nursing staff.
Report Facts
Residents affected: 1
Residents reviewed for MDS assessment timing: 9
Residents affected: 1
Residents reviewed for SCIC MDS assessment timing: 3
Residents affected: 1
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Confirmed urine on bathroom floor and odor for resident #8 | |
| Administrator | Stated expectation for bathroom cleanliness and nurse staffing data posting | |
| Director of Clinical Services | Confirmed late MDS assessments for residents #1 and #2 | |
| Front Desk Clerk | Responsible for posting nurse staffing data, confirmed data was not posted on 07/10/25 |
Inspection Report
Routine
Census: 98
Deficiencies: 17
Date: Jun 5, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, staffing, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to notify providers of missed or partial medication doses, failure to provide a comfortable environment, failure to ensure appropriate use of psychotropic medications, inaccurate resident assessments, incomplete care plans, insufficient staffing levels, failure to provide necessary behavioral health care, failure to secure medication carts, improper food storage, incomplete medical records, and inadequate infection prevention practices.
Deficiencies (17)
Failure to treat residents with dignity and respect, including failure to use privacy bags for catheter bags and improper meal service.
Failure to notify providers of missed medication doses and treatments for residents.
Failure to provide a comfortable and homelike environment, including storage of deceased resident belongings in common areas and unrepaired floor and ceiling damage.
Failure to ensure gradual dose reduction and proper documentation for psychotropic medications.
Failure to ensure accurate Minimum Data Set (MDS) assessments for residents.
Failure to create accurate baseline care plans within 48 hours of admission.
Failure to develop and implement complete, person-centered care plans with appropriate interventions.
Failure to revise care plans to reflect current resident conditions and interventions.
Failure to provide care meeting professional standards, including failure to follow orders for compression stockings.
Failure to provide adequate assistance with activities of daily living, including toenail and nail care.
Failure to maintain appropriate staffing levels to meet resident needs.
Failure to ensure residents received necessary behavioral health care and consistent psychiatric services.
Failure to ensure drugs and biologicals are stored securely and labeled according to professional standards.
Failure to procure, store, and label food in accordance with professional standards.
Failure to maintain complete and accurate medical records.
Failure to electronically submit complete and accurate direct care staffing information to CMS.
Failure to provide and implement an effective infection prevention and control program, including failure to implement enhanced barrier precautions.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 69
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 98
Residents affected: 1
Residents affected: 69
Residents affected: 94
Residents affected: 2
Residents affected: 98
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Confirmed lack of privacy bag on catheter and staffing shortages |
| LPN #28 | Licensed Practical Nurse | Observed unlocked treatment cart and confirmed lack of gown use for EBP |
| DON | Director of Nursing | Multiple interviews confirming deficiencies in care, staffing, infection control, and care planning |
| RN #9 | Registered Nurse | Reported staffing shortages and resident care delays |
| CNA #10 | Certified Nursing Assistant | Reported staffing shortages and care delays |
| CNA #16 | Certified Nursing Assistant | Confirmed lack of fall mat and staffing shortages |
| LPN #16 | Licensed Practical Nurse | Confirmed medication administration issues and lack of gown use |
| Administrator | Facility Administrator | Confirmed staffing issues and lack of psychiatric follow-up |
| Wound Care Nurse | Confirmed wound care and infection control deficiencies | |
| Regional Nurse Consultant | Confirmed medication and care plan deficiencies | |
| Activities Director | Described limited dementia activities provided | |
| Medical Records Coordinator | Observed rushing and poor meal service to resident |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 18, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report allegations of abuse, failure to create accurate baseline care plans within 48 hours of admission, failure to provide medication orders and pharmaceutical services properly, and failure to meet professional standards of care.
Complaint Details
The complaint investigation found that the facility failed to report abuse allegations timely, failed to create baseline care plans timely, and failed to provide proper medication orders and administration, all of which could lead to harm or worsening conditions for residents.
Findings
The facility failed to timely report allegations of resident-to-resident abuse within two hours to the State Agency for 5 residents. The facility also failed to create an accurate baseline care plan within 48 hours for one resident, failed to obtain and enter medication orders for two residents, and failed to provide routine medication for one resident, resulting in potential harm or worsening of conditions.
Deficiencies (4)
Failed to timely report allegations of abuse within two hours to the State Agency for 5 residents.
Failed to create an accurate baseline care plan within 48 hours of admission for 1 resident.
Failed to obtain and enter medication orders for 2 residents upon admission or return from hospital.
Failed to provide routine medication (pregabalin) for 1 resident, resulting in unnecessary pain.
Report Facts
Residents affected by abuse reporting deficiency: 5
Residents reviewed for baseline care plans: 2
Residents affected by baseline care plan deficiency: 1
Residents reviewed for medication orders: 3
Residents affected by medication order deficiency: 2
Residents affected by pharmaceutical services deficiency: 1
Dates of incidents not reported timely: 3
Pregabalin doses not administered: 7
Inspection Report
Deficiencies: 4
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan development and revision requirements for residents, focusing on whether the facility developed accurate, person-centered comprehensive care plans and updated care plans after significant events such as falls.
Findings
The facility failed to develop accurate and comprehensive care plans for residents R #2 and R #21, including missing diagnoses and failure to include functional abilities. Additionally, the care plan for R #21 was not revised after a fall, potentially resulting in staff being unaware of current resident needs and appropriate interventions.
Deficiencies (4)
Failed to develop an accurate, person-centered comprehensive care plan for residents R #2 and R #21.
Diagnosis of schizophrenia was not included in R #2's history and physical form.
R #21's care plan did not include functional abilities as required.
R #21's care plan was not revised to include the fall on 05/05/24 or interventions to prevent future falls.
Report Facts
Residents reviewed for care plans: 5
Residents reviewed for care plan revision: 3
Date of care plan for R #2: 05/23/24
Date of history and physical for R #2: 05/24/24
Date of Minimum Data Set Assessment for R #21: 04/24/24
Date of care plan for R #21: 04/23/24
Date of fall for R #21: 05/05/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed missing schizophrenia diagnosis and care plan revision issues for R #2 and R #21 | |
| MDS Coordinator | Confirmed care plan omissions and failure to revise care plan after fall for R #21 |
Inspection Report
Routine
Census: 100
Deficiencies: 4
Date: Apr 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, and facility operations including resident accommodations, meal service, emergency protocols, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had call lights and bedside items within reach, improper meal serving practices in the secure unit, inconsistent documentation and communication of residents' code status leading to potential inappropriate CPR administration, and unsanitary kitchen conditions with improper food holding temperatures.
Deficiencies (4)
Failed to ensure residents' bedside table with frequently used items and call light were within reach for 2 residents.
Failed to provide a home-like environment by leaving meals on serving trays during lunch for 16 residents in the secure unit.
Failed to ensure staff knew and followed facility protocols for residents' code status and had code status available during emergencies for 3 residents, risking inappropriate CPR.
Failed to maintain clean and sanitary kitchen conditions and failed to hold puree cold foods at 41°F or lower, risking foodborne illness for all 100 residents.
Report Facts
Residents affected: 2
Residents affected: 16
Residents affected: 3
Residents affected: 100
Temperature: 88.5
Temperature: 84.7
Temperature: 93.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #31 | Confirmed resident #359 did not have call light within reach | |
| ADON #2 | Confirmed bedside table and pitcher not within reach for resident #102 and confirmed meal serving practices and code status issues | |
| Activities Assistant | Confirmed meals were left on serving trays in secure unit | |
| DON | Confirmed meal serving practices and code status procedures | |
| Social Services Director (SSD) | Confirmed code status documentation and procedures | |
| LPN #22 | Interviewed about code status process and EMR usage | |
| LPN #11 and LPN #24 | Interviewed about code status binder and CPR procedures | |
| Kitchen Supervisor | Confirmed kitchen cleanliness issues and missing ice machine cleaning logs | |
| Dietary Manager | Measured food temperatures and confirmed food temperature standards |
Inspection Report
Routine
Census: 101
Deficiencies: 25
Date: Apr 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to notify providers of changes in condition, inadequate safeguarding of resident information, failure to maintain grievance records, delayed abuse reporting, failure to provide timely transfer notices and bed hold notices, untimely and inaccurate MDS assessments, incomplete baseline and comprehensive care plans, failure to monitor medications and lab results properly, inadequate pain management, failure to provide proper infection control measures, and incomplete staff training on QAPI.
Deficiencies (25)
Failed to ensure resident's bedside table and call light were within reach for 2 residents.
Failed to notify provider of change in condition for resident with nausea and potential drug interactions.
Failed to safeguard resident medical record information; computer screen left unlocked.
Failed to provide a home-like environment by leaving meals on serving trays for 16 residents in secure unit.
Failed to maintain grievance records for up to three years.
Failed to report allegations of abuse within two hours to State Agency.
Failed to provide written transfer notices and bed hold notices to residents and representatives.
Failed to complete Significant Change MDS assessment within 14 days.
Failed to complete quarterly MDS assessments timely for 3 residents.
Failed to ensure accurate MDS assessment for resident dependent on staff for tube feeding.
Failed to develop baseline care plans within 48 hours for 2 residents; psychotropic medications not listed.
Failed to develop comprehensive care plans for 2 residents; missing diagnoses and treatments.
Failed to revise care plans to reflect current diagnoses and treatments for 4 residents.
Failed to provide treatment and care according to orders for resident with chronic kidney disease and elevated potassium, resulting in death.
Failed to assist resident in gaining access to vision services; no eye doctor appointments for resident with glaucoma.
Failed to provide ordered nutritional supplements for resident with decreased oral intake.
Failed to effectively manage pain for resident; pain assessments and provider notifications were inadequate.
Failed to monitor antiseizure medication levels as ordered for resident.
Failed to ensure psychotropic medications were prescribed with appropriate diagnoses for 3 residents.
Failed to maintain clean and sanitary food preparation and storage areas; puree cold foods held above 41°F.
Failed to maintain complete and accurate medical records for 2 residents.
Failed to maintain effective infection prevention and control program; PPE not available for residents on enhanced barrier precautions and staff did not wear eye protection for Covid-19 positive resident.
Failed to document routine surveillance findings for infection control program.
Failed to offer Covid-19 vaccination to resident and document offer.
Failed to ensure nursing staff completed mandatory QAPI training.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 101
Residents affected: 16
Residents affected: 101
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 100
Residents affected: 2
Residents affected: 6
Residents affected: 1
Staff affected: 5
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where a resident (R #1) received another resident's medications, resulting in hospitalization and adverse health effects.
Complaint Details
The complaint investigation was triggered by an incident on 06/02/23 where a new traveling nurse (LPN #31) administered another resident's medications to R #1, resulting in hospitalization. The allegation of neglect was substantiated. The facility failed to timely report the incident to the State Agency. The investigation found deficiencies in staff competency and training.
Findings
The facility failed to timely report an allegation of neglect related to a medication error where a new traveling nurse administered medications to the wrong resident. This resulted in the resident being hospitalized with adverse effects including hypotension and altered mental status. The facility also failed to ensure nursing staff competency and proper onboarding for medication administration. Additionally, call light cords in resident bathrooms were found to be too short, posing a safety risk.
Deficiencies (4)
Failed to timely report suspected abuse, neglect, or theft to proper authorities.
Failed to ensure nursing staff demonstrated competency in medication administration, resulting in medication error and resident hospitalization.
Failed to ensure residents are free from significant medication errors, resulting in adverse side effects and hospitalization.
Failed to ensure call lights in residents' bathrooms had properly functioning pull cords accessible to residents on the floor.
Report Facts
Residents affected: 1
Residents sampled for neglect: 6
Hospitalization duration: 6
Medications administered in error: 9
Residents affected by call light deficiency: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #31 | Charge Nurse | Allowed LPN #31 to administer medications independently and was notified of medication error. |
| LPN #31 | Traveling Nurse | Administered wrong medications to R #1 and was involved in the medication error incident. |
| RN #1 | Nurse | Did not receive onboarding training or competency checks related to medication administration. |
| RN #33 | Nurse | Started working in July 2023, shadowed other nurses, completed basic competencies. |
| LPN #32 | Nurse | Started working July 2023, shadowed nurses, did not complete competencies or trainings. |
| Administrator | Facility Administrator | Confirmed inability to find initial report to State Agency and competency documents for new staff. |
| DON | Director of Nursing | Provided information on training expectations and competency documentation. |
| Physician/Medical Director | Physician | Provided medical opinion on medication effects and resident condition. |
Inspection Report
Routine
Census: 72
Deficiencies: 26
Date: Apr 6, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident care, medication management, abuse prevention, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, personal funds management, resident rights to survey results, advance directives, abuse prevention and reporting, loss of personal property, care planning, medication administration errors, infection control, staff training, and rehabilitation services.
Deficiencies (26)
Failed to ensure residents were treated with respect and dignity, including language barriers, bed linens, and room odor.
Failed to provide quarterly statements for resident's personal funds.
Failed to ensure residents knew where the most recent survey results were located.
Failed to ensure completion of advance directives for residents.
Failed to notify resident's representative of an abuse incident.
Failed to protect residents against loss of personal property.
Failed to keep residents free from abuse by staff, including physical and mental abuse.
Failed to timely report an allegation of abuse to the State Survey Agency within two hours.
Failed to notify residents or representatives in writing of transfers and reasons for move.
Failed to provide written notice of bed hold policy at time of transfer.
Failed to complete comprehensive assessment within 14 days of admission.
Failed to complete significant change MDS assessment within 14 days of change.
Failed to submit and finalize MDS assessments in a timely manner.
Failed to ensure accurate MDS assessments, including incorrect PTSD diagnosis and vision impairment severity.
Failed to create a baseline care plan with interventions within 48 hours of admission.
Failed to develop a comprehensive person-centered care plan including tube feeding.
Failed to ensure proper insulin administration and medication sharing.
Failed to maintain Foley catheter tubing and collecting bag off the floor.
Failed to conduct nurse aide performance reviews annually and provide required in-service training.
Failed to ensure pharmacist recommendations were reviewed and implemented or rationale provided.
Failed to discontinue or reevaluate psychotropic medications used as PRN beyond 14 days.
Medication errors including missed doses and wrong medications given.
Failed to properly secure medication carts and remove expired medications.
Failed to provide restorative rehabilitation services as ordered.
Failed to perform proper hand hygiene between feeding residents.
Failed to provide nurse aides with dementia care and abuse prevention training.
Report Facts
Residents affected: 72
Deficiency count: 25
Medication error rate: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed medication errors including wrong medication and shared insulin pen |
| DON | Director of Nursing | Provided multiple confirmations and interviews regarding deficiencies and corrective actions |
| PTA #11 | Physical Therapist Assistant | Involved in multiple abuse allegations and physical mistreatment of residents |
| ADON #1 | Assistant Director of Nursing | Witnessed abuse incident involving PTA #11 and resident R #21 |
| ADON #2 | Assistant Director of Nursing | Witnessed abuse incident involving PTA #11 and resident R #21 |
| RN #11 | Registered Nurse | Interviewed regarding resident upset after abuse incident |
| LPN #11 | Licensed Practical Nurse | Confirmed expired medications in medication cart |
| CNA #22 | Certified Nursing Assistant | Observed feeding residents without hand hygiene |
| Administrator | Facility Administrator | Provided interviews regarding multiple deficiencies including abuse reporting and restorative program |
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