Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coronado Care Center during CMS and state inspections, most recent first.
Surveyors observed that open bags of hash browns and French fries in the facility's walk-in freezer were not labeled or dated. The DM confirmed this did not meet expectations for proper food storage, resulting in a deficiency for not maintaining sanitary conditions for food storage and service.
Staff did not update or revise care plans for several residents after changes in their care needs or interventions. This included not documenting the use of a trapeze bar for mobility, failing to update hospice care status, not removing a discontinued communication board intervention, and omitting a DNR advance directive from the care plan. These omissions were confirmed through observations, record reviews, and staff interviews.
A medication aide failed to sanitize hands, disinfect equipment, and wear gloves during medication administration, resulting in a medication error rate of 10.34%. These lapses were confirmed by both the aide and the DON, and were not in accordance with facility policy or CDC guidelines.
Surveyors observed that two residents had their call lights placed on the bed and out of reach while they were asleep in recliners. Both a hospice nurse and a CNA confirmed that the call lights should have been accessible to the residents.
Staff failed to keep hallways accessible, as medication carts and a shower chair were observed on both sides of the hallway in two separate wings, blocking the path for residents. Both a Restorative Nursing Aide and a CMA confirmed that these items were obstructing the hallway and should have been kept on one side.
A resident with a documented DNR order did not have their advance directive form, the New Mexico Orders for Scope and Treatment (MOST), available in either the EHR or in physical form for staff. The DON confirmed the absence of the MOST form despite the DNR status being noted in other records.
A resident with Alzheimer's, dementia, and other cognitive and mobility issues was placed in a recliner that prevented her from getting up without assistance. Staff confirmed the recliner was used to keep the resident, who was prone to wandering, in one place, despite the care plan not including this intervention or documenting it as medically necessary.
A resident with multiple chronic conditions and newly initiated hospice care did not have a Significant Change MDS assessment completed and transmitted within the required 14-day period after the facility identified a major change in condition. Documentation showed the assessment was started but not finished, and the MDS did not reflect the resident's hospice status.
A CMA did not sanitize vital sign equipment before use, failed to perform hand hygiene before a medication pass, and did not wear gloves when handling medication for three residents. The DON confirmed that staff are expected to follow these infection control protocols.
The facility failed to ensure that a Nurse Aide completed the required CNA state licensure exam within four months of employment. The NA was hired and working full-time but had not obtained her CNA license within the required timeframe, as confirmed by the DON.
The facility failed to store food in accordance with professional standards, with issues including a box of grape juice on the floor, unlabeled and undated items in the walk-in refrigerator, and unsealed items in the freezer. The Dietary Manager confirmed these deficiencies and stated that all kitchen staff were responsible for proper food storage.
The facility failed to ensure enough food was available to serve all residents the meal on the menu and to provide second portions when requested. Observations and interviews revealed that the facility frequently ran out of food and coffee, affecting residents' ability to receive complete meals and additional servings.
The facility failed to ensure the accuracy of the PASRR assessment for a resident diagnosed with schizophrenia. The PASRR incorrectly documented that the resident did not have a mental illness, despite having a diagnosis of schizophrenia. This discrepancy was confirmed during interviews with the Admissions Coordinator and the Social Services Director.
The facility failed to ensure residents were invited to attend care plan meetings. One resident was not woken up for her meeting despite expressing a desire to attend, and another resident reported never being invited to a care plan meeting, with no documentation found in his records.
A facility failed to assess and remove a Foley catheter for a resident with a Stage 4 pressure ulcer, despite the resident being alert, oriented, and able to use a bedside commode. The resident expressed a desire to have the catheter removed, but this request was not communicated to the medical director, and no trial voiding was attempted.
The facility failed to provide an adaptive eating device for a resident during dining observation. The resident had a physician's order to use a plate guard for meals, but the meal ticket did not direct staff to provide it. During observation, the resident ate without the plate guard until a CNA placed it on the plate later in the meal. The CNA acknowledged the oversight.
Failure to Label and Date Food Items in Freezer
Penalty
Summary
During an observation of the facility's walk-in freezer, surveyors found two bags of what appeared to be hash browns and two bags of what appeared to be French fries that were open and undated. The Dietary Manager confirmed during an interview that these items were not labeled or dated, which did not meet his expectations for food storage. The report notes that this practice failed to ensure food items were stored and served under sanitary conditions, as required by professional standards. The deficiency was identified as potentially affecting 76 residents listed on the facility's census at the time of the survey.
Failure to Update and Revise Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised for five residents following changes in their care needs or interventions. For one resident with multiple diagnoses including multiple sclerosis and muscle weakness, a trapeze bar was observed in use for mobility and repositioning, but this intervention was not reflected in the care plan. The Director of Nursing confirmed that the care plan had not been revised to include this equipment. Two residents receiving or previously receiving hospice care did not have their care plans updated accordingly. One resident's care plan contained outdated hospice interventions from over a year prior, despite the resident no longer being on hospice. Another resident, currently on hospice as indicated by the Minimum Data Set, had no mention of hospice care in the comprehensive care plan. The Assistant Director of Nursing confirmed these omissions and stated that care plans should be revised to reflect hospice status when relevant. Additional deficiencies included a resident with a cognitive communication deficit whose care plan listed the use of a communication board with word cards, although this intervention was no longer in use and not available in the resident's room. Staff interviews confirmed the communication board was ineffective and had been discontinued, but the care plan was not updated. Another resident with a DNR advance directive had this order documented in the medical record and on the MOST form, but the care plan did not reflect the DNR status. The Director of Nursing confirmed the care plan was not revised after the DNR order was established.
Medication Error Rate Exceeds Acceptable Threshold Due to Lapses in Hand Hygiene and Equipment Disinfection
Penalty
Summary
Staff failed to maintain a medication error rate below 5%, with 3 medication errors observed out of 29 opportunities, resulting in a 10.34% error rate. During medication administration, a Certified Medication Aide (CMA) did not clean the blood pressure cuff and vital sign equipment before taking a resident's vitals, did not sanitize her hands before beginning a medication pass for another resident, and failed to don gloves before opening a capsule for a third resident. These actions were directly observed during the survey. The CMA confirmed during interview that she should have sanitized her hands before the medication pass, cleaned the vital sign equipment before and between each resident, and worn gloves before handling medications. The Director of Nursing also confirmed that staff are expected to follow these procedures. Review of facility policy and CDC guidelines further supported the requirement for hand hygiene and equipment disinfection before and after resident contact and medication administration.
Call Lights Not Accessible to Residents in Rooms
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents in their rooms for two out of four residents reviewed for call light accessibility. In one instance, a resident was observed asleep in a recliner while the call light was placed on top of the bed, out of her reach. This was confirmed by a hospice nurse who stated that the call light should have been accessible. In another case, a different resident was also found asleep in a recliner with the call light similarly placed on the bed and not within reach, which was confirmed by a certified nurse assistant. These observations were made during surveyor rounds and were corroborated by staff interviews.
Hallway Accessibility Obstructed by Equipment
Penalty
Summary
Facility staff failed to ensure that hallways were accessible for residents, as observed on two separate occasions. On the [NAME] Wing, a medication cart was found on the right side of the hallway near one room, and a shower chair was on the left side near another room, resulting in objects on both sides of the hallway. During an interview, the Restorative Nursing Aide confirmed that these items were blocking the residents' path and stated that all items should be kept on one side to maintain a clear passage. Similarly, in the South Wing, two medication carts were observed on opposite sides of the hallway near different rooms, again obstructing the path. The Certified Medication Aide interviewed at that time also confirmed the presence of objects on both sides of the hallway and acknowledged that items should be kept on one side.
Advance Directive Not Available in EHR or Physical Form
Penalty
Summary
The facility failed to ensure that a resident's current advance directive, specifically the New Mexico Orders for Scope and Treatment (MOST), was available in the resident's Electronic Health Record (EHR) or in physical form for staff access. Record reviews showed that the resident was admitted to the facility and had a documented Do Not Resuscitate (DNR) order in both the physician orders and care plan. However, the actual advance directive form was not present in the EHR or available physically. During an interview, the Director of Nursing confirmed that the MOST form was missing from both the EHR and physical records, despite the resident's DNR status being documented elsewhere.
Resident Restrained in Recliner Without Medical Necessity
Penalty
Summary
A resident with diagnoses including Alzheimer's, dementia, depression, cognitive communication deficit, unsteadiness on feet, and a psychotic disorder with hallucinations was observed in situations that led to the use of a physical restraint. The resident's care plan included interventions such as providing diversions, structured activities, education, close supervision, and regular rounds to address her risk of elopement and wandering. However, during observation, the resident was seen attempting to leave the dining room in her wheelchair and later attempting to get out of a recliner with the footrest extended. A Certified Nursing Assistant (CNA) stated that the recliner was used to keep the resident, who was identified as a wanderer, safely in one place. The CNA confirmed that the resident could not get out of the recliner without assistance. This use of the recliner as a restraint was not documented as a medical necessity and was not part of the resident's care plan interventions, resulting in the resident not being free from physical restraints.
Failure to Complete and Transmit Significant Change MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a Significant Change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's condition. Specifically, a resident with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, cerebral aneurysm, and chronic heart failure was admitted to the facility and later started on hospice care. The resident's clinical census and physician order indicated that hospice services began, but the MDS assessment did not reflect this change, and the Significant Change MDS was started but not completed within the required timeframe. During interviews, the resident confirmed being on hospice, while the MDS Coordinator acknowledged that the Significant Change MDS assessment was not completed as expected. The record review showed discrepancies between the resident's current care status and the documentation in the MDS, indicating that the facility did not follow the mandated timeline for updating and transmitting the assessment after a major change in the resident's health status.
Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
Certified Medication Aide (CMA) #1 failed to follow proper infection prevention and control practices for three residents. Specifically, the CMA did not clean the blood pressure cuff and vital sign equipment before taking vital signs for one resident, did not sanitize her hands before beginning a medication pass for another resident, and did not don gloves before opening a medication capsule for a third resident. During interviews, the CMA acknowledged these lapses, and the Director of Nursing confirmed that staff are expected to perform hand hygiene before and after each medication pass and to sanitize equipment and don gloves as required.
Failure to Ensure Nurse Aide Competency
Penalty
Summary
The facility failed to provide documentation confirming that a Nurse Aide (NA) employed by the facility had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed. The NA was hired on 12/01/23 and was working full-time as of 05/17/24. Although the NA completed the CNA training, she did not complete the CNA state licensure exam within the required timeframe. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the NA did not obtain her CNA license within four months of her hire date.
Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards of food service safety. In the dry storage area, a 10-pound box of grape juice was observed stored on the bare floor. The Dietary Manager (DM) confirmed that items should not be on the floor and should be stored on shelves, and that all kitchen staff were responsible for ensuring this standard was met. In the walk-in refrigerator, several food items were found not labeled or dated, including a small pan of orange fluff salad, a single tomato wrapped in saran wrap, a 2-quart plastic container of apple sauce, a case of sour cream packets, an open pack of flour tortillas, two packs of corn tortillas, and two 2-quart pitchers of juice. The DM confirmed that all items should be labeled and dated, and that all kitchen staff were responsible for this task. In the facility freezer, a box of beef patties, a box of cookie dough, and a box of Salisbury steak patties were found open to air and not sealed. The DM confirmed that these items should be sealed to avoid freezer burn and that staff were expected to close the boxes after removing food items.
Facility Fails to Provide Adequate Food and Second Portions
Penalty
Summary
The facility failed to ensure that there was enough food to serve all residents the meal on the menu and to provide second portions when requested. During a dining observation, it was noted that some residents were served meals without vegetables because the facility ran out of vegetables. Interviews with staff and residents confirmed that the facility frequently ran out of food and coffee, with residents reporting that this occurred at least twice a week. One resident mentioned that the facility often did not provide coffee with meals, especially in the morning and evening, because only one pot of coffee was made to avoid waste. Another resident stated that the facility ran out of food often, affecting their ability to receive a complete meal as per the menu. Additionally, the facility failed to serve second portions of meals when requested by residents. Multiple residents reported that they seldom received second servings because the kitchen did not have enough food. During a dining observation, residents asked for a second helping of egg salad but were told that there were no second portions available because the kitchen had run out. Staff interviews confirmed that the kitchen often ran out of food, leaving residents unable to get additional servings. This deficiency affected the nutritional needs and preferences of the residents, as they were often left hungry and unable to receive the full meal as planned.
Inaccurate PASRR Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for a resident diagnosed with schizophrenia. The resident's most recent PASRR, dated 12/27/21, incorrectly documented that the resident did not have a mental illness, despite having a diagnosis of schizophrenia. This discrepancy was confirmed during interviews with the Admissions Coordinator and the Social Services Director, who acknowledged that the PASRR should have included the schizophrenia diagnosis. The PASRR was initially completed by the discharging hospital, but facility staff did not review it for accuracy prior to the resident's admission.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents were invited to attend care plan meetings, as evidenced by the cases of two residents. Resident #23 was admitted to the facility and expressed a desire to be involved in her care plan meetings. However, she did not attend her last care plan meeting because she was napping, and the nursing staff decided not to wake her. The Social Services Director (SSD) acknowledged that the meeting should have been rescheduled to accommodate Resident #23's participation. This indicates a failure to respect the resident's expressed wishes and to involve her in her care planning process. Resident #30, who was also admitted to the facility, reported that he had never been invited to a care plan meeting. A review of his Electronic Health Record confirmed the absence of documentation indicating that a care plan meeting had been held for him. The SSD admitted that there was no Care Plan Conference form for Resident #30 in his records, which should have been maintained. This lack of documentation and failure to invite the resident to participate in care planning highlights a significant oversight in the facility's care planning process.
Failure to Assess and Remove Foley Catheter
Penalty
Summary
The facility failed to ensure a resident admitted with an indwelling Foley catheter was assessed for its removal. The resident, who was admitted with a Stage 4 pressure ulcer, had a Foley catheter in place to prevent the wound from getting infected or soiled. Despite the resident being alert, oriented, and able to use a bedside commode, the catheter was not removed, and no trial voiding was attempted. The resident expressed a desire to have the catheter removed, but this request was not communicated to the medical director by the staff. Interviews with the LPN, DON, and NP revealed that there was no clear diagnosis related to the Foley catheter use, and no attempts were made to discontinue the catheter since the resident's admission. The medical director stated that if a resident is cognitively aware and able to use a bedside commode, the expectation would be to attempt to discontinue the catheter as soon as possible. However, the staff did not inform the medical director of the resident's wish to have the catheter removed. The wound care nurse confirmed that the resident's wound remained stable and that the resident did not experience pain during dressing changes or when using the bedside commode, indicating that the resident could sustain transfers and bedside toileting without pain. This lack of action likely contributed to the resident not regaining bladder control and potentially developing bladder incontinence or a bladder infection.
Failure to Provide Adaptive Eating Device
Penalty
Summary
The facility failed to provide an adaptive eating device for a resident during dining observation. The resident had a physician's order dated 05/13/24 to use a plate guard for meals to improve self-feeding skills. However, the resident's meal ticket did not direct staff to provide the adaptive feeding equipment. During a dining observation on 05/13/24, the resident ate her meal without the plate guard until a CNA placed it on the plate later in the meal. The CNA acknowledged that the resident had an order for the plate guard and should have been served with it initially.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portales
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Retirement Ranches Inc. | 18.6 mi | ★★★★★ | 9 | 0 |
| St. Anthony Healthcare And Rehabilitation Center | 18.7 mi | ★★★★★ | 37 | 0 |
| Clovis Healthcare And Rehabilitation Center | 19.2 mi | ★★★★★ | 23 | 0 |
| Farwell Care And Rehabilitation Center | 23.1 mi | ★★★★★ | 21 | 0 |
| Park View Nursing Care Center | 35.1 mi | ★★★★★ | 24 | 2 |
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