Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Gallup Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow physician-ordered parameters for blood pressure (BP) medications for two residents. For one resident, lisinopril was given despite a systolic BP below the ordered hold parameter. For another resident, carvedilol was withheld on two occasions even though the documented BP and heart rate were within the ordered range for administration, and required nursing notes explaining the omissions were not entered. The DON confirmed that vital signs should be documented in the MAR and that medications must be administered or held according to provider orders, which did not occur in these cases.
Surveyors found that a resident room had multiple strips of floor tape that were worn, curling, and leaving sticky, uneven residue near the bedside area, and that a hallway near the dining room had a hose connected to a wall-mounted water source by an ice machine that was not properly secured in its protective case, causing water to drip and form a puddle on the floor. The Maintenance Supervisor and the ADM acknowledged that floor tape should remain flat and that the hose should be secured to prevent tripping and slipping hazards for residents.
Surveyors found that multiple resident rooms and bathrooms were not maintained in safe and functional condition, including windowsills separating from walls with visible gaps, loose tiles near beds, damaged heating vents, and an electrical outlet housing separated from the wall. Walls and bathroom doors in several rooms had scuff marks, chipped or uneven paint, and visible unpainted wood putty. According to the Maintenance Supervisor, surfaces should be evenly painted, windowsills should not separate from walls, and rooms are expected to be kept in good repair so that residents feel at home.
A resident was admitted and did not have a baseline care plan developed within 48 hours as required by facility policy. Record review showed the baseline care plan was initiated more than two days after admission. In interviews, the DON and the Administrator confirmed their expectation that baseline care plans be completed within 48 hours, and acknowledged that this did not occur for this resident.
A resident with HTN and cardiac conditions had a physician order for carvedilol to be held only if SBP was below a specified threshold or HR was under 60 bpm. On two occasions, the MAR showed carvedilol doses as not administered with instructions to see a nurse or progress note, even though the recorded vital signs were within ordered parameters for administration. No corresponding nursing or progress notes were found to explain why the doses were held, while other doses with similar vital signs were documented as given. The DON confirmed that when a medication is marked as held with a direction to see a note, a note explaining the reason is expected, and acknowledged the medical record was not accurate.
A resident with dementia, bladder neck obstruction, and an indwelling Foley catheter for chronic urinary retention was observed on multiple occasions without required catheter privacy measures and with improper tubing positioning. The facility’s policy required drainage bags to be covered with a privacy bag when out of bed and catheter tubing to be secured off the floor. During meal and common-area observations, the resident’s drainage bag lacked a privacy cover and the catheter tubing was seen touching the floor. CNAs, the DON, and the Administrator all acknowledged that catheter bags should be covered and tubing should not drag on the floor, confirming that established infection control procedures were not followed.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall resulting in a head injury. Despite facility policy, no neurological checks were documented, leading to a delay in identifying a severe brain bleed. The resident's condition worsened, resulting in hospitalization and eventual passing.
A resident experienced an unwitnessed fall resulting in a head injury, which was not reported to the SSA as required by the facility's policy. The resident was found on the floor with a cut over the right eye and later sent to the ER for a CT scan due to altered mental status. The incident was not logged in the facility's Incident Report Log, and the administrator was unaware of the event, as the responsible agency nurse was no longer employed.
The facility's binding arbitration agreement failed to include a provision for selecting a convenient venue for arbitration proceedings. This deficiency was confirmed by the facility Administrator and noted during a record review. Although the facility's Admission Guide mentioned the provision, it lacked a signed acknowledgment from residents, potentially affecting 56 of the 57 residents who signed the agreement.
A resident felt disrespected when a staff member closed his room door without proper communication, as his music was deemed too loud during a nearby meeting. The Housekeeping Manager informed the roommate instead of the resident and did not wait for a response, assuming agitation. This action violated the resident's rights to dignity and respect.
A facility failed to create a Baseline Care Plan within 48 hours for a newly admitted resident with complex medical conditions, including acute respiratory failure and post-COVID-19 condition. The plan was completed three days post-admission, as confirmed by the Administrator, which deviated from required protocols.
A resident with hepatic encephalopathy did not receive a prescribed dose of lactulose due to staff holding the medication after the resident experienced loose stools. The DON clarified that the medication was intended to manage encephalopathy, not constipation, and loose stools were a sign of the medication's effectiveness.
Failure to Follow BP Medication Parameters and Document Withheld Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not following physician orders for blood pressure medications for two residents. For one resident, a physician’s order dated 07/16/25 directed that lisinopril be held if the systolic blood pressure was less than 110 mmHg. Review of the Medication Administration Record (MAR) from 01/01/26 to 01/21/26 showed that on 01/05/26, staff administered lisinopril despite a documented systolic blood pressure of 105 mmHg, which was below the ordered hold parameter. For the second resident, a physician’s order dated 11/20/25 specified that carvedilol for hypertension be held only if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute. The MAR for 01/01/26 to 01/21/26 showed that on 01/01/26, a dose of carvedilol was not administered and was marked “see progress note,” even though the recorded systolic blood pressure was 118 mmHg and heart rate was 70 beats per minute, both within parameters; the corresponding progress notes from 01/01/26 to 01/02/26 contained no documentation explaining the withheld dose. On 01/16/26, the evening dose of carvedilol was again not administered and referenced a nurse’s note, while the MAR documented a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the ordered parameters, and nursing notes from 01/16/26 to 01/17/26 did not document a reason for withholding the medication. During an interview, the DON confirmed that vital signs are expected to be documented in the electronic MAR and that medications should be administered or held according to the provider’s parameters, and acknowledged that staff did not follow the orders in these instances.
Failure to Maintain Safe Flooring and Control Water Leakage Hazards
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe environment when multiple strips of adhesive tape were observed on the bedroom floor near the bedside area in Room 41. Several of these tape strips were worn, partially detached, and curling upward at the edges, and dark adhesive residue remained where tape had deteriorated or been removed, creating uneven and sticky surface areas. These conditions were directly observed in the resident room and were acknowledged by the Maintenance Supervisor, who stated his expectation that tape applied to floors should be flat to the ground to prevent a tripping hazard. Surveyors also observed a deficiency in the hallway leading to the dining room, where a hose connected to a wall-mounted water source next to the ice machine was actively dripping water onto the floor, forming a small puddle. The hose was supposed to be secured within a clear plastic protective case, but the case did not securely hold the hose in place, allowing the dripping to occur in an area accessible to all residents. In interviews, both the Maintenance Supervisor and the Administrator stated that the hose nozzle should be secured inside the clear plastic case to prevent water from dripping onto the floor and that tape placed on the floor should remain flat with the surface to prevent residents from tripping or falling.
Failure to Maintain Safe and Functional Resident Room Environments
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, and functional physical environment in multiple resident rooms and bathrooms. Observations showed that several windowsills were separating from the wall, unpainted, or had loose tiles, including in rooms near specific beds where gaps of approximately 0.5 to 1 inch were noted between the sill and the wall. In one room, the windowsill closest to a bed was unpainted and separating from the wall, while in other rooms the windowsills near beds had loose tiles or were separating from the wall. An electrical outlet housing behind a bed was also observed to be separated from the wall. Additional observations revealed scuff marks, chipped paint, and uneven paint coverage on bathroom walls and other wall surfaces in several rooms. One room’s interior bathroom door had visible, unpainted wood putty, and the bathroom door and multiple walls had uneven paint coverage, with scuffed walls behind a bed. Another room’s heating vent had three broken horizontal slats, indicating the vent was damaged and could not properly control the flow of warm air, and the same room’s bathroom walls had scuff marks and chipped paint. During an interview, the Maintenance Supervisor stated that scuff marks should be painted evenly, windowsills should be in good repair and not separating from the wall, and that it was his expectation that resident rooms be in good repair so residents feel like they are at home.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident. The facility’s policy on Care Plans – Baseline, dated December 2016, required that a baseline care plan be developed within 48 hours of a resident’s admission to ensure the resident’s immediate care needs are met and maintained. Record review showed that the resident was admitted on an identified date, but the baseline care plan for this resident was not initiated until 01/12/26, which was more than 48 hours after admission. During interviews, the DON stated that it was her expectation that the resident’s baseline care plan should have been completed on 01/11/26, and the Administrator stated that it was her expectation that residents’ baseline care plans be completed within 48 hours of admission. This deficiency was identified for 1 of 1 resident reviewed for baseline care plans and was based on record review of the resident’s face sheet and baseline care plan, as well as staff interviews confirming that the facility did not meet its own policy requirement for timely completion of the baseline care plan.
Incomplete Documentation of Held Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to medication administration for one resident prescribed carvedilol for hypertension and other cardiac conditions. The physician’s order dated 11/20/25 directed that carvedilol be held only if the resident’s systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute. Review of the Medication Administration Record (MAR) for 01/01/26 showed the morning dose of carvedilol was documented as not administered with a direction to “see progress note,” while the recorded vital signs that morning were a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which were within the ordered parameters for administration. No corresponding progress note was found for that date explaining why the medication was withheld. Further review of the MAR from 01/01/26 to 01/21/26 showed that the evening dose of carvedilol on 01/01/26 was documented as administered, with the same vital signs recorded for that evening as in the morning (systolic blood pressure 118 mmHg and heart rate 70 beats per minute). On 01/16/26, the evening dose of carvedilol was again documented on the MAR as not administered with a notation to “see nurses note,” yet the resident’s vital signs that day showed a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the parameters for giving the medication. No nursing note was entered on 01/16/26 or 01/17/26 to explain the reason for withholding the dose. In an interview, the DON stated that when a nurse documents a medication as held with a direction to see a note, it is expected that a corresponding note be entered, and confirmed that the resident’s medical record regarding medication administration was not accurate.
Failure to Maintain Catheter Privacy and Tubing Position per Infection Control Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care and infection prevention procedures for a resident with an indwelling Foley catheter. The facility’s Catheter Care Procedure, last revised June 2020, required that catheter drainage bags be kept below the level of the bladder, off the floor, and covered with a privacy bag when the resident is out of bed. The resident, originally admitted with dementia and bladder neck obstruction and assessed with a BIMS score indicating severe cognitive impairment, had physician orders for an indwelling Foley catheter PRN for chronic urinary retention. During a lunch observation in the dining room, the resident was seen sitting in a wheelchair with the catheter drainage bag uncovered, without the required privacy bag. In a separate observation in a common TV area, the same resident was seen in a wheelchair with the urinary catheter tubing touching the floor, contrary to the facility’s policy to keep tubing off the floor. Staff interviews confirmed that these practices did not meet facility expectations: a CNA stated that all residents should have a privacy bag covering their urinary drainage bags, another CNA reported that the previous CNA had forgotten to attach the catheter bag to the chair and acknowledged that the tubing should not be dragged on the floor, and both the DON and the Administrator confirmed that catheter tubing should not touch the ground and that a privacy bag should always be in place when residents are out of their rooms. These observations and statements demonstrate that the facility did not maintain its infection prevention and control program for this resident’s catheter care.
Failure to Conduct Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall that resulted in injury. The resident, who had a history of frequent falls and was at high risk for falls due to multiple medical conditions including Parkinson's Disease, dementia, and generalized muscle weakness, was found on the floor with a laceration over his right eye. Despite the facility's policy requiring neurological checks for 72 hours following an unwitnessed fall, no neuro evaluations were completed or documented for the resident. The resident's condition deteriorated over the following days, with vital signs indicating changes and a noted alteration in mental status. The resident was eventually sent to the emergency room for a CT scan, which revealed a large left temporal lobe bleed and other significant brain hemorrhages. The lack of timely and appropriate neurological assessments likely contributed to the delay in identifying the resident's life-threatening condition. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the expected neurological checks were not performed. The facility's failure to adhere to its own post-fall assessment and monitoring policy resulted in the resident's hospitalization and subsequent passing, highlighting a significant deficiency in the care provided to the resident.
Failure to Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury for a resident to the State Survey Agency (SSA), as required by their policy. The incident involved a resident who was found on the floor in their room with a cut over the right eye. The nursing progress notes indicated that the resident was later sent to the emergency room for a CT scan due to a change in mental status. Despite these events, the facility's Incident Report Log did not contain any record of the fall being reported. The facility's policy mandates that a licensed nurse complete an incident report and perform a post-fall assessment following each resident fall. Additionally, a Neurological Flow Sheet should be completed for any unwitnessed fall or witnessed fall with a head injury. However, the administrator confirmed that the incident was not reported to her, and thus, not filed with the SSA. The nurse responsible for documenting the fall was an agency nurse who is no longer employed at the facility, which contributed to the failure in reporting the incident.
Arbitration Agreement Lacks Venue Provision
Penalty
Summary
The facility failed to ensure that their binding arbitration agreement included a provision for the selection of a convenient venue, which is necessary for arbitration proceedings. This omission could potentially deter residents from exercising their rights to seek arbitration due to the inconvenience and frustration it may cause. The deficiency was identified during a record review of the facility's Voluntary Arbitration Agreement, which was found to be undated and lacking the necessary provision. During an interview, the facility Administrator confirmed the absence of this provision in the arbitration agreement, although it was mentioned in the facility's Admission Guide. However, the Admission Guide did not include a signed acknowledgment from residents confirming receipt, understanding, and inclusion of this provision as part of the Voluntary Arbitration Agreement. This issue has the potential to affect 56 of the 57 facility residents who signed the binding arbitration agreement.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
The facility failed to uphold a resident's rights to dignity and respect when a staff member closed a resident's room door against his wishes and without proper communication. The incident involved a resident who was listening to music at a volume audible in the hallway. The Housekeeping Manager (HM) closed the door at the request of the facility Administrator due to a nearby staff meeting. The HM informed the resident's roommate instead of the resident himself and did not wait for the resident's response, assuming he was agitated. This action led the resident to feel disrespected and uncared for by the staff.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a Baseline Care Plan within 48 hours of admission for one of the residents reviewed. This deficiency was identified during a record review and interview process. The resident in question, identified as R #108, was admitted with multiple complex medical conditions, including acute respiratory failure with hypoxia, type 2 diabetes mellitus with neuropathy, hyperlipidemia, obstructive sleep apnea, hypertension, atherosclerotic heart disease, congestive heart failure, pneumonia due to coronavirus disease, asthma, muscle wasting and atrophy, overactive bladder, difficulty in walking, and post-COVID-19 condition. Despite these significant health issues, the baseline care plan, which is crucial for ensuring immediate and appropriate care, was not created until more than 48 hours after the resident's admission. The delay in creating the baseline care plan was confirmed during an interview with the facility's Administrator, who acknowledged that the staff did not complete the plan within the required timeframe. The baseline care plan for the resident was only completed three days after admission, which is a clear deviation from the expected protocol. This oversight could potentially lead to a decline in the resident's condition due to the staff's lack of awareness of the necessary care requirements, as the baseline care plan is essential for guiding immediate care upon admission.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to meet professional standards of practice in the administration of medication for a resident diagnosed with hepatic encephalopathy. The resident was prescribed lactulose, a medication intended to decrease ammonia levels in the blood, to be administered 45 milliliters by mouth three times a day. However, a review of the Medication Administration Record for September 2024 revealed that the midday dose of lactulose was not administered on September 3, 2024, due to a note to hold the medication. The nurse's progress note indicated that the resident had experienced three loose stools since the morning, which led to the decision to withhold the medication. During an interview, the Director of Nursing stated that the lactulose should not have been held due to loose stools, as the medication was prescribed to manage encephalopathy, not constipation, and loose stools were indicative of the medication's desired effect.
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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 Gallup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Red Rocks Care Center | 3.6 mi | ★★★★★ | 15 | 0 |
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