Inspection Report Summary
The most recent inspection on November 18, 2025, identified deficiencies related to mobility accommodations, professional standards for urinalysis collection, and medication security. Earlier inspections showed a pattern of issues including care planning, resident dignity, medication management, timely notifications, and staff training. Complaint investigations found a late reporting deficiency for abuse and misappropriation cases, but no fines or enforcement actions were listed in the available reports. Prior reports noted challenges with maintaining a homelike environment, accurate assessments, and behavioral health training. The facility’s deficiencies have persisted over time with no clear pattern of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident accommodations, professional standards of care, and medication security at Casa Del Sol Center.
Findings
The facility failed to provide reasonable accommodation for residents' mobility needs due to an inaccessible outdoor gazebo ramp, failed to meet professional standards by not collecting a physician-ordered urinalysis sample, and failed to secure medications properly, leaving medication carts unlocked and accessible.
Deficiencies (3)
Failed to provide reasonable accommodation of resident needs for mobility due to an inaccessible ramp to the outdoor gazebo blocked by medical equipment.
Failed to meet professional standards of practice by not collecting a urinalysis sample as ordered by the physician.
Failed to assure medications were secured and inaccessible; medication cart found unlocked and unattended.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding placement of shower chair on gazebo ramp | |
| Unit Manager | Confirmed no urinalysis results on file and medication cart was unlocked |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident property and abuse involving two residents, R #20 and R #58, to investigate the facility's reporting and follow-up on these incidents.
Complaint Details
The complaint involved two residents: R #20 reported $45 taken from her purse with unknown timing or perpetrator, and R #58 reported pain caused by an improper transfer by a staff member. The facility completed investigations but failed to submit follow-up reports within five days, submitting them late on 03/11/25 and 03/18/25 respectively.
Findings
The facility failed to report the results of investigations of misappropriation of resident property and allegations of abuse within five days to the State Agency for two residents. The investigations were completed but the follow-up reports were submitted late.
Deficiencies (1)
Failed to timely report the results of investigations of misappropriation of resident property and allegations of abuse to the State Agency within five days.
Report Facts
Dollar amount taken: 45
Residents affected: 2
Inspection Report
Routine
Deficiencies: 20
Date: Mar 10, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care, including resident rights, environment, care planning, medication management, and staff competencies.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during meals, inadequate maintenance of the environment, failure to notify residents and representatives of transfers, untimely and inaccurate Minimum Data Set assessments, incomplete and inaccurate care plans, medication administration errors, inadequate pain management, delayed wound care orders, incomplete provider documentation, improper medication storage, failure to provide dental services, insufficient dining space, and lack of behavioral health training for staff.
Deficiencies (20)
Failed to ensure a resident was treated with respect and dignity during meal assistance by staff standing instead of sitting beside the resident.
Failed to provide a homelike environment in good condition by not repairing broken windowsill trimming in a resident's room.
Failed to provide timely notification to resident and representative of hospital transfers in writing and to the Ombudsman.
Failed to complete comprehensive Minimum Data Set (MDS) assessments within required timeframes after admission and significant change in condition.
Failed to ensure accurate MDS assessments for multiple residents, including incorrect medication and diagnosis coding.
Failed to develop and implement complete, accurate, and person-centered care plans including timely interdisciplinary team meetings and updates for changes in resident condition.
Failed to administer medications according to physician's orders, resulting in missed doses due to delayed medication reorder and delivery.
Failed to provide activities of daily living assistance, specifically oral care, resulting in inconsistent teeth brushing and lack of documentation.
Failed to obtain and implement wound care orders timely for pressure ulcers present on admission.
Failed to provide safe and appropriate pain management by delaying initiation of prescribed pain medication for 16 days after provider visit.
Failed to ensure residents' doctors provide written, signed, and dated progress notes at each required visit.
Failed to ensure nursing assistants had competency evaluations at hire and routinely thereafter.
Failed to complete performance reviews at least every 12 months for nursing assistants.
Failed to properly store medications including disposal of loose tablets, dating open medications, and documenting refrigerator temperatures.
Failed to keep residents free from unnecessary psychotropic medications by lacking consents and appropriate diagnoses for medication use.
Failed to provide or obtain routine dental services for residents, resulting in lack of dental visits since admission.
Failed to serve food under sanitary conditions by not performing hand hygiene prior to assisting residents with eating and drinking.
Failed to safeguard resident-identifiable information and maintain complete and accurate medical records, including monitoring for anticoagulant use.
Failed to provide sufficient dining space, resulting in crowded conditions that hinder safe movement and disrupt dining experience.
Failed to provide behavioral health training consistent with requirements for nursing assistants.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
CNAs affected: 3
CNAs affected: 2
Residents affected: 57
Residents affected: 3
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 57
CNAs affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Named in findings related to dignity during meal assistance, ADL assistance, hand hygiene, and lack of competency and behavioral health training |
| CNA #9 | Certified Nursing Assistant | Named in findings related to dignity during meal assistance and lack of competency evaluation |
| CNA #16 | Certified Nursing Assistant | Named in findings related to dignity during meal assistance, hand hygiene, lack of competency and performance evaluations |
| DON | Director of Nursing | Provided expectations for meal assistance, care planning, medication management, and staff competencies |
| Unit Manager | Unit Manager | Confirmed care plan meeting attendance, medication administration issues, and monitoring requirements |
| MDS Coordinator | MDS Coordinator | Confirmed MDS assessment timing and accuracy issues, care plan deficiencies |
| Nurse Practice Educator | Nurse Practice Educator | Confirmed lack of competency evaluations and behavioral health training for CNAs |
| CMA #16 | Certified Medication Aide | Confirmed medication reorder delays and medication storage issues |
| Social Services Worker | Social Services Worker | Confirmed lack of transfer notification to Ombudsman and care plan meeting scheduling issues |
| Records Manager | Records Manager | Confirmed lack of dental care for resident |
| Wound Care Nurse | Wound Care Nurse | Confirmed delayed wound care orders and lack of timely wound care consultant notes |
| Infection Control Nurse | Infection Control Nurse | Confirmed hand hygiene expectations during meal assistance |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident rights, care planning, environment, notification procedures, assessments, pressure ulcer prevention, dialysis care, and call light functionality at Casa Del Sol Center.
Findings
The facility was found deficient in multiple areas including failure to provide proper Medicare/Medicaid coverage notices, maintain a homelike environment, timely notification of transfers and bed hold policies, accurate assessments, comprehensive and revised care plans, pressure ulcer prevention, restorative nursing services, dialysis care orders, and functioning call light systems.
Deficiencies (11)
Failed to provide resident R#2 with Form CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage.
Failed to repaint walls after repairs in resident R#48's room, affecting homelike environment.
Failed to provide timely written notice of transfer to resident R#51.
Failed to provide written notice of bed hold policy to resident R#51.
Failed to ensure accurate Minimum Data Set assessment for resident R#46 by omitting depression diagnosis.
Failed to develop and implement comprehensive care plans for residents R#1 and R#38.
Failed to revise care plan for resident R#8 to include hearing aid assistance.
Failed to provide appropriate pressure ulcer prevention care for residents R#4 and R#18 due to use of mattress extenders instead of properly fitting pressure-redistribution mattresses.
Failed to start restorative nursing program services for residents R#8 and R#38 as recommended after physical therapy discharge.
Failed to obtain physician's orders for dialysis treatment and post-dialysis monitoring for resident R#7.
Failed to maintain a functioning call light system in resident R#12's room.
Report Facts
Residents reviewed for beneficiary notices: 3
Residents reviewed for environment: 3
Residents reviewed for hospitalization: 1
Residents reviewed for MDS accuracy: 3
Residents reviewed for comprehensive care plans: 5
Residents reviewed for activities of daily living: 6
Residents reviewed for call lights: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Stated she did not provide R#2 with Form CMS-10055 |
| Maintenance Director | Maintenance Director | Confirmed wall repairs not repainted in R#48's room and call light replacement for R#12 |
| Administrator | Administrator | Confirmed failure to provide written transfer notice and bed hold policy notice for R#51 |
| MDS Coordinator | MDS Coordinator | Confirmed R#46's quarterly MDS did not include depression diagnosis despite active medication |
| Director of Nursing | Director of Nursing | Confirmed R#1 had falls and no care plan for falls |
| Central Supply Manager | Central Supply Manager | Confirmed mattress extenders used for residents R#4 and R#18 |
| Unit Manager | Unit Manager | Confirmed R#8's care plan not revised to include hearing aid assistance |
| Director of Rehabilitative Services | Director of Rehabilitative Services | Confirmed R#8 and R#38 did not receive restorative nursing program services |
| LPN #31 | Licensed Practical Nurse | Confirmed R#7 had no orders for dialysis treatment or post-dialysis care |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Nov 21, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, grievance resolution, timely abuse reporting, accuracy of resident assessments, care plan revisions, vision care follow-up, staff competency and training, medication management, infection control, and medication storage.
Deficiencies (12)
Failed to treat resident with respect and dignity by not cleaning resident after breakfast, leaving food and nasal discharge on resident.
Failed to make prompt efforts to resolve grievances related to missing property.
Failed to timely report allegations of abuse to the State Agency within 2 hours.
Failed to have an accurate resident assessment by not removing resolved pneumonia diagnosis from MDS.
Failed to revise care plans to reflect discontinued medication, add counseling, and include ADL interventions.
Failed to follow up with resident's eye doctor regarding eyeglasses after appointment.
Failed to ensure nurse aides had competencies necessary to care for residents.
Failed to conduct performance reviews for nurse aides every 12 months.
Failed to have attending physician document rationale for declining pharmacy recommendations.
Failed to properly store medication cart locked when not in use.
Failed to follow proper infection control practices by allowing oxygen tubing on floor and uncovered nebulizer masks.
Failed to provide nurse aides with 12 hours of annual training associated with facility assessment.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
CNAs affected: 2
CNAs affected: 2
Residents affected: 5
Residents affected: 17
Residents affected: 2
CNAs affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Named in vision care follow-up and medication cart storage findings | |
| Social Services Director | SSD | Interviewed regarding resident grievances and care plan revisions |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including dignity, care plans, medication storage, and training |
| Assistant Director of Nursing | ADON | Interviewed regarding medication review deficiency |
| Medical Record Manager | MRM | Interviewed regarding vision care follow-up |
| Human Resources | HR | Interviewed regarding CNA competencies and training |
| Transporter | Interviewed regarding oxygen tubing on floor | |
| Infection Preventionist | IP | Interviewed regarding infection control practices |
| CNA #7 | Certified Nursing Assistant | Named in competency and training deficiencies |
| CNA #8 | Certified Nursing Assistant | Named in competency and training deficiencies |
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