Inspection Reports for
Coronado Care Center
1604 WEST 18TH STREET, PORTALES, NM, 88130
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than New Mexico average
New Mexico average: 7.1 deficiencies/year
Deficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
95% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 76
Deficiencies: 9
Date: Jun 13, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' advance directives in records, improper use of physical restraints, incomplete significant change assessments, failure to update care plans, medication administration errors exceeding acceptable rates, improper food storage, inadequate infection control practices, inaccessible call lights for residents, and unsafe hallway conditions.
Deficiencies (9)
Failed to ensure resident's current advance directive was available in the Electronic Health Record or physical form.
Failed to keep residents free from physical restraints unless medically necessary.
Failed to complete and transmit a Significant Change Minimum Data Set assessment within 14 days after a significant change in condition.
Failed to revise care plans timely for multiple residents to include use of trapeze bar, hospice care, communication board removal, and advance directives.
Medication error rate exceeded 5 percent with 3 errors out of 29 opportunities.
Failed to label and date food items stored in the facility's freezer.
Failed to maintain proper infection prevention practices including hand hygiene and equipment sanitation during medication administration.
Failed to ensure call lights were within reach of residents in their rooms.
Failed to maintain hallways free of obstructions, blocking residents' path.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Medication errors: 3
Medication error rate: 10.34
Residents affected: 76
Residents affected: 3
Residents affected: 2
Residents affected: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide #1 | Named in medication error and infection prevention findings | |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including advance directive, care plan revisions, medication errors, and infection control |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Named in physical restraint and communication board findings |
| Assistant Director of Nursing #2 | Assistant Director of Nursing (ADON) | Named in care plan revision findings |
| Dietary Manager | Dietary Manager (DM) | Named in food storage deficiency |
| Hospice Nurse #1 | Hospice Nurse (HN) | Named in call light deficiency |
| Certified Nurse Assistant #2 | Certified Nurse Assistant (CNA) | Named in call light deficiency |
| Restorative Nursing Aide | Restorative Nursing Aide (RNA) | Named in hallway obstruction deficiency |
Inspection Report
Routine
Capacity: 75
Deficiencies: 7
Date: May 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, food service, staff training, and facility operations at Coronado Care Center.
Findings
The facility was found deficient in multiple areas including inadequate food availability and second servings for residents, inaccurate PASRR documentation, failure to invite residents to care plan meetings, improper catheter management, unlicensed nurse aide employment, failure to provide adaptive eating devices, and improper food storage practices.
Deficiencies (7)
Facility failed to ensure enough food was available to serve all residents the meal on the menu and failed to serve second portions when requested.
PASARR screening was inaccurate for one resident, failing to document a diagnosis of schizophrenia.
Facility failed to ensure residents were invited to attend care plan meetings for two residents reviewed.
Facility failed to assess removal of Foley catheter for one resident, resulting in potential for bladder control issues or infection.
Facility failed to provide documentation confirming one nurse aide completed required training and licensure within four months of employment.
Facility failed to provide an adaptive eating device for one resident during dining observation.
Facility failed to ensure proper food storage practices including storing food off the floor, labeling and dating items in the refrigerator, and sealing items in the freezer.
Report Facts
Residents affected: 75
Residents affected: 68
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Employed full time without CNA license within four months of hire |
| Director of Nursing | Director of Nursing | Interviewed regarding nurse aide licensure and catheter care |
| Admissions Coordinator | Admissions Coordinator | Interviewed regarding PASRR screening accuracy |
| Social Services Director | Social Services Director | Interviewed regarding PASRR screening and care plan meetings |
| Medical Director | Medical Director | Interviewed regarding Foley catheter management |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and labeling deficiencies |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed and observed regarding meal service and adaptive eating device |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Foley catheter care |
| ADON/Wound Care Nurse | Assistant Director of Nursing/Wound Care Nurse | Interviewed regarding wound status and catheter care |
Inspection Report
Routine
Census: 54
Capacity: 90
Deficiencies: 11
Date: May 16, 2023
Visit Reason
Routine inspection visit to assess compliance with regulatory requirements including dining environment, care planning, medication management, infection control, and resident safety.
Findings
The facility was found to have multiple deficiencies including overcrowded and noisy dining area impeding safe movement and resident comfort, incomplete and untimely care plans for residents, medication order discrepancies, inadequate pain management, failure to provide trauma-informed care, poor food quality and temperature control, improper food storage, infection control lapses, call light systems not within reach for several residents, and insufficient dining space.
Deficiencies (11)
Dining area overcrowded causing difficulty in movement, high noise levels, and blocked egress.
Failure to develop and implement comprehensive care plans for residents with significant health needs.
Failure to timely revise and update care plans for residents reviewed for pain management.
Inadequate pain management for a resident resulting in unrelieved pain and diminished quality of life.
Failure to provide trauma-informed care and mental health services for a resident with PTSD.
Pharmaceutical services failed to ensure accurate medication dispensing due to conflicting pharmacy orders.
Food served was not palatable, often cold due to delayed delivery, and menus were not posted.
Food storage deficiencies including unlabeled, undated food items and food stored on bare floors.
Infection prevention and control program failures including unclean shower areas, uncovered trash, and shared personal items.
Call light systems not within reach for multiple residents, impairing ability to summon assistance.
Insufficient dining space causing overcrowding, noise, and difficulty for residents to safely move and dine.
Report Facts
Residents in dining area: 54
Fire Marshall occupancy limit: 90
Weight loss percentage: 15.45
Weight loss percentage: 25.7
Weight loss percentage: 24.6
Pain ratings: 5
Medication administration times: 24
Meal delivery delay: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Dietary Director | Confirmed dining area overcrowding and noise, stated plan to correct | |
| Administrator (ADM) | Acknowledged fire Marshall occupancy limit and difficulty maneuvering in dining area | |
| Director of Nursing (DON) | Confirmed nutritional weight loss plan not developed, pain management issues, call light accessibility problems, and lack of PTSD care plan | |
| Licensed Practical Nurse (LPN) #1 | Observed resident in pain, confirmed inadequate pain control | |
| Minimum Data Set (MDS) Coordinator/Care Plan Coordinator (CPC) | Acknowledged errors in smoker status and care plans | |
| President of Clinical Operations (VPCO) | Responded to medication order conflicts and alerted DON and pharmacy | |
| Director of Dietary Services (DDS) | Described meal preparation and delivery process, acknowledged food temperature issues and missing menu displays | |
| Assistant Director of Nursing | Acknowledged infection control issues with personal items in shower room | |
| Certified Nursing Aide (CNA) #6 | Reported on infection control issues and assisted resident with call light and protein bar | |
| Infection Preventionist (IP) | Confirmed call light accessibility issues |
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