Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
111% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
96 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident discharge planning and the functionality of call light systems in the facility.
Findings
The facility failed to ensure home health services were in place prior to discharge for one resident, potentially risking negative health outcomes. Additionally, the facility failed to maintain a functioning call light system for two residents, which could prevent residents from summoning staff in emergencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure home health services were in place prior to discharge for 1 of 4 residents reviewed for discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a functioning call light system for 2 of 2 residents reviewed for call lights. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services (SS) | Interviewed regarding discharge and home health service setup | |
| CNA #1 | Certified Nursing Assistant | Confirmed call light was not functioning during observation |
| HHA representative | Interviewed regarding home health agency records for discharged resident |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician of a resident's change in condition, specifically a fever, and failure to maintain complete and accurate medical records for residents.
Findings
The facility failed to notify the physician when a resident developed a fever and administered medication without physician approval, and failed to maintain complete and accurate medical records documenting changes in residents' conditions, which could lead to worsening health outcomes.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify the physician of a resident's fever and failure to maintain accurate medical records documenting changes in condition and events leading to hospitalization or death.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the physician of a change in condition when a resident developed a fever and administered medication against physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure quality care by not following medical orders and notifying the provider about changes in a resident's onset of fever. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medical records for residents, resulting in lack of documentation of changes in condition and events leading to hospitalization or death. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication dosage: 650
Resident count reviewed: 6
Residents affected: 1
Residents affected: 2
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 17
Dec 12, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, inaccurate resident assessments, incomplete and outdated care plans, inadequate supervision leading to resident smoking violations, improper catheter care, medication errors, failure to post nurse staffing data, lack of pharmacist medication regimen reviews, expired medications and supplies, insufficient food service staffing, absence of a quality assurance and performance improvement plan, failure to implement infection control and antibiotic stewardship programs, and failure to properly offer and document pneumococcal and COVID-19 vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Level of Harm - Potential for minimal harm: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to keep residents free from physical restraints by using bed rails without orders, consent, or assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete comprehensive care plans for residents, missing key medication and condition details. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans timely to reflect changes in resident conditions and treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent resident smoking violations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate Foley catheter care, including incomplete physician orders and lack of catheter maintenance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post nurse staffing information daily at the beginning of shifts. | Level of Harm - Potential for minimal harm |
| Failed to ensure consultant pharmacist's medication regimen reviews were completed and physician responses documented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' drug regimens were free from unnecessary drugs and lacked monitoring for side effects. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration errors occurred, including mixing medications in feeding tubes contrary to policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all medications and medical supplies were not expired. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient support personnel for food and nutrition services, resulting in delayed meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an ongoing infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a comprehensive antibiotic stewardship program. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement policies and procedures for flu and pneumonia vaccinations, including failure to offer pneumococcal vaccine and document consent/refusal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents, and properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 96
Medication errors: 3
Medication error rate: 6.45
Residents affected: 2
Residents affected: 3
Meal service delay: 53
Meal service delay: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn [Last Name Redacted] | Director of Nursing | Confirmed incomplete care plans and medication monitoring deficiencies |
| Administrator | Confirmed lack of QAPI plan, antibiotic stewardship program, and late meal service | |
| Registered Nurse #2 | RN | Observed medication administration error via feeding tube |
| Registered Nurse #1 | RN | Confirmed expired medications and supplies should be discarded |
| CNA #1 | Certified Nursing Assistant | Confirmed resident smoked in room despite policy |
| Director of Nursing | DON | Multiple interviews confirming deficiencies in assessments, care plans, infection control, and medication management |
Inspection Report
Routine
Deficiencies: 4
Nov 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, pressure ulcer care, and nutrition management at Spring River Rehabilitation and Care Center.
Findings
The facility failed to ensure accurate Minimum Data Set assessments, develop comprehensive person-centered care plans, provide appropriate pressure ulcer care, and adequately monitor and address significant weight loss in multiple residents. These deficiencies could lead to residents not receiving necessary services, worsening medical conditions, and actual harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Actual harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure accuracy of the Minimum Data Set Assessment for one resident, missing documentation of significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive person-centered care plans for two residents, omitting key care needs such as wound care, surgical site, foley catheter, colostomy, and significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care for two residents, including lack of consistent wound assessments, delayed wound care orders, and failure to implement wound care interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor residents' weights, assess causes of unintentional weight loss, and implement interventions to prevent further weight loss for four residents, resulting in actual harm. | Level of Harm - Actual harm |
Report Facts
Weight loss percentage: 24.8
Weight loss percentage: 47.6
Weight loss percentage: 11.43
Weight loss percentage: 29.5
Weight loss percentage: 22.9
Weight loss percentage: 11.75
Weight loss percentage: 20
Weight loss percentage: 29.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed significant weight loss and deficiencies in care planning and wound care |
| Director of Clinical Operations | Director of Clinical Operations (DCO) | Registered dietician who confirmed significant weight loss and lack of appropriate monitoring |
| Administrator | Administrator (ADM) | Interviewed regarding nutrition and weight loss issues |
Inspection Report
Complaint Investigation
Deficiencies: 9
Sep 6, 2024
Visit Reason
The inspection was conducted due to complaints regarding residents' rights violations, abuse reporting, care plan deficiencies, medication handling, and staff training at Spring River Rehabilitation and Care Center.
Findings
The facility failed to honor residents' rights, timely report and investigate abuse allegations, complete accurate care plans, meet professional care standards, secure medication carts, maintain complete medical records, and ensure CNAs received required in-service training. Several residents experienced dignity violations, improper catheter care, and unsafe medication handling.
Complaint Details
The complaint investigation revealed substantiated grievances regarding residents' rights violations, verbal abuse, failure to report abuse timely, incomplete investigations, and inadequate staff training. Specific incidents included improper use of mechanical lifts against resident wishes, refusal to assist with incontinence care during meals, staff yelling at residents, and failure to report and investigate abuse allegations promptly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to honor residents' rights to dignified existence, self-determination, communication, and exercise of rights for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse within two hours to the State Survey Agency for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete and document a thorough investigation and provide a follow-up report within five working days for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to create and put into place a baseline care plan within 48 hours of admission for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement accurate and complete care plans with measurable timetables and actions for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet professional standards of quality including improper transfer causing catheter removal, lack of physician orders for catheter care, and unsafe medication handling for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all treatment carts were locked and secured while unattended, risking unauthorized access to medical supplies and personal health information. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safeguard resident-identifiable information and maintain complete and accurate medical records for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Certified Nurse Aides received the required 12 hours of annual in-service training for dementia care and abuse prevention for 3 CNAs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 103
Residents affected: 1
CNAs affected: 3
Required CNA training hours: 12
CNA #2 training hours completed: 2
CNA #3 training hours completed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in resident dignity violation and grievance substantiation |
| CNA #4 | Certified Nursing Assistant | Named in resident dignity violation incident |
| LPN #1 | Licensed Practical Nurse | Named in resident dignity violation and policy misunderstanding |
| LPN #2 | Licensed Practical Nurse | Named in resident dignity violation incident |
| CNA #1 | Certified Nursing Assistant | Named in verbal abuse allegation and incomplete training |
| Certified Medical Assistant #2 | Certified Medical Assistant | Named in unsafe medication handling |
| Certified Medical Assistant #3 | Certified Medical Assistant | Named in medication cart security interview |
| Administrator | Administrator | Responsible for abuse reporting and staff training oversight |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care expectations and deficiencies |
Inspection Report
Routine
Census: 94
Deficiencies: 13
Feb 9, 2024
Visit Reason
Routine inspection of Spring River Rehabilitation and Care Center to assess compliance with regulatory requirements including resident rights, care planning, medication administration, activities, infection control, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate grievance resolution communication, inaccurate resident assessments, incomplete care plans, missed medication doses, insufficient activities programming, lack of assistive devices for vision, improper respiratory care, medication errors exceeding 5%, improper medication storage including expired supplies, and failure to maintain infection prevention practices such as sterile catheter care and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure staff knocked on resident's bedroom door before entering, violating resident dignity. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure grievances identified by Resident Council were resolved and communicated back. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Minimum Data Set (MDS) assessments were accurate for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive, person-centered care plans including preferences and discharge goals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive care plans within 7 days of assessment and revise timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received treatment per physician orders, including missed antibiotic doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities designed to meet interests of all residents, especially bed bound residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist resident in gaining access to vision services and replacement of assistive devices. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly date oxygen tubing or chart changes in Electronic Treatment Administration Record. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5%, with errors in inhaled medication administration and eye drop technique. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement adequate monitoring of behaviors for residents on psychotropic medications and lacked required consent forms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications and biologicals were properly stored, expired supplies removed, wound care supplies separated, refrigeration maintained, opened insulin pens dated, and controlled substances secured. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper infection prevention measures including reuse of urinary catheter drainage system and failure to perform hand hygiene prior to donning gloves. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 94
Medication errors: 4
Medications administered: 35
Medication error rate: 11.43
Residents reviewed for activities: 11
Residents reviewed for psychotropic medication monitoring: 4
Expired supplies: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in dignity deficiency for not knocking before entering resident room |
| Activities Director for the Memory Care Unit | Activities Director | Confirmed staff expected to knock before entering rooms |
| Interim Administrator | Administrator | Signed grievance response form and confirmed grievance resolution process |
| Interim Director of Nursing | Director of Nursing | Confirmed grievance communication issues and lack of grievance documentation |
| MDS Coordinator | Minimum Data Set Coordinator | Confirmed inaccurate MDS assessment for resident |
| MDS Nurse (MDS #1) | Minimum Data Set Nurse | Confirmed incomplete care plans and delayed care plan completion |
| Director of Nursing (DON) | Director of Nursing | Confirmed missed antibiotic doses, medication administration errors, infection control deficiencies, and medication storage issues |
| Activities Assistant (AA) | Activities Assistant | Described limited activities programming and one-on-one activities |
| Unit Manager (UM #1) | Unit Manager | Acknowledged medication cart cleanliness issues and undated insulin pen |
| Certified Nursing Assistant (CNA #5) | Certified Nursing Assistant | Confirmed oxygen tubing undated |
| Licensed Practical Nurse (LPN #2) | Licensed Practical Nurse | Observed medication administration errors and hand hygiene failure |
| Nurse Aide (NA #1) | Nurse Aide | Described reuse of urinary drainage system |
| Central Supply Coordinator | Supply Coordinator | Confirmed expired supplies in medication supply room |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 9, 2024
Visit Reason
The visit was conducted to assess and document deficiencies related to accident hazards and supervision in the nursing home environment, specifically following a resident fall incident.
Findings
The facility failed to ensure a safe environment free from accident hazards when a resident (R #92) fell and hit her head on a hoyer lift left unattended in the hallway, resulting in injury requiring sutures or staples. Staff were re-educated on proper storage of hoyer lifts, and subsequent observations showed compliance with this practice.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure residents were free from accident hazards, resulting in a resident fall and head injury caused by an unattended hoyer lift in the hallway. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Date of fall: Dec 4, 2023
Date of care plan initiation: Sep 28, 2023
Date of follow-up investigation: Dec 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anonymous Staff | Witnessed the resident fall and reported staff leaving hoyer lifts in the hallway | |
| interim Director of Nursing | Director of Nursing | Provided information about the fall incident and staff education on hoyer lift storage |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to safeguard residents' money and properly manage residents' financial affairs, specifically concerning missing funds from residents' trust accounts.
Findings
The facility failed to act as a fiduciary for four residents by not safeguarding their funds and failing to report quarterly on the status of these funds. A total of $2,117.00 was signed out for resident spend down, but $1,675.20 went missing and was later reimbursed. The facility did not notify families or residents promptly, and internal controls were inadequate, including lack of locked storage for resident funds.
Complaint Details
The complaint investigation revealed missing funds totaling $1,675.20 from residents' trust accounts between 10/27/2023 and 11/06/2023. The facility called police for an internal investigation. The missing money was reimbursed, but the facility failed to notify families and residents timely. The investigation could not establish who stole the money, so misappropriation was not confirmed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure residents' money was safeguarded from loss and failed to act as fiduciary for residents' funds, resulting in unaccounted money and lack of proper reporting. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 4
Amount signed out: 2117
Amount missing: 1675.2
Account balance R#1: 309.38
Account balance R#2: 597.14
Account balance R#3: 407.66
Account balance R#4: 361.02
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Business Manager | Assistant Business Manager | Interviewed regarding unawareness of missing money and process of resident trust funds |
| Activity Director | Activity Director | Oversaw residents' spend down money and was in possession of missing funds |
| Administrator in Training | Administrator in Training | Interviewed about notification of families and residents and internal investigation |
| Business Office Manager | Business Office Manager | Interviewed about handling of residents' money and lack of follow-up on missing funds |
| Facility Administrator | Administrator | Interviewed about the incident, responsibilities, and notification of families |
| Corporate Business Supervisor | Corporate Business Supervisor | Interviewed regarding proper procedures for handling resident funds and follow-up |
Inspection Report
Annual Inspection
Deficiencies: 10
Nov 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Spring River Rehabilitation and Care Center.
Findings
The facility was found deficient in multiple areas including failure to maintain cleanliness, incomplete care plans for oxygen use, improper oxygen tubing management, inadequate feeding assistance, lack of hospice care documentation, inconsistent meal service, improper medication storage, poor food quality and temperature, unsafe food storage practices, and failure to provide timely vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to maintain residents bathroom cleanliness for 1 resident by not cleaning bathroom floor in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive person-centered care plan for 2 residents for use of oxygen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet professional standards of care for 2 residents by not initialing, dating, and changing oxygen tubing weekly per physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure feeding assistance was provided for 1 resident reviewed for ADLs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to keep record of the Hospice plan of care and care visits for 1 resident reviewed for Hospice services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to consistently offer meals for 1 resident reviewed for meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure unused medications or supplies were properly disposed of for 36 residents sampled. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide meals that followed the menu, tasted good, and served at an appetizing temperature for 2 residents reviewed for food quality. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store and serve food under sanitary conditions by not ensuring food and beverages stored in resident nourishment refrigerators and freezers were labeled, dated, and not expired. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure that 1 resident was provided flu and pneumonia vaccinations in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 36
Residents affected: 2
Residents affected: 1
Pills found: 10
Pills found: 7
Meal delay: 15
Meal delay: 28
Meal temperature: 115
Meal temperature: 132
Meal temperature: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of oxygen care plans, medication cart issues, feeding assistance responsibility, and vaccination deficiency |
| Housekeeping Supervisor | Housekeeping Supervisor | Acknowledged bathroom floor was dirty and should have been cleaned |
| Restorative Certified Nursing Assistant #1 | Restorative Certified Nursing Assistant | Confirmed oxygen tubing was not initialed or dated for resident #23 |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Confirmed oxygen tubing was not initialed or dated for resident #44 |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Unaware of food tray in front of resident #44 |
| Dietary Manager | Dietary Manager | Confirmed food tray issues, meal temperature problems, and unlabeled food in nourishment refrigerators |
| Registered Nurse #1 | Registered Nurse | Unaware of pills found in medication cart |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed pills should not be in medication cart drawers |
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