Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 New Mexico State Veterans Home during CMS and state inspections, most recent first.
Failure to Provide Behavioral Health Treatment and Psychotherapy: A resident with PTSD, depression, anxiety, and suicidal thoughts did not receive the consistent counseling/psychotherapy that was documented as needed, another resident with bipolar disorder and reported hallucinations was not reported to the PMHNP or referred for psychiatric consult, and a third resident with MDD, schizophrenia, dementia, GAD, and recurrent SI repeatedly sought psychiatric care but the record did not show follow-through with psychiatrist services or psychotherapy notes.
The facility failed to provide adequate mental health services for two residents with mental health diagnoses, including Bipolar Disorder, Depression, and PTSD. One resident expressed feelings of depression and hopelessness without receiving psychiatric evaluation or behavioral health services. Another resident on hospice expressed a wish to die, yet there was no documentation of social services provided. The facility lacked psychiatric providers, and interventions were limited to medication and chaplain visits.
A facility failed to honor a resident's right to self-determination by not allowing him to leave independently, despite having a contract for independent travel. The resident, who was cognitively intact, expressed his desire to leave the facility on his own, particularly for church, but was repeatedly informed by staff that he could not do so without supervision due to safety concerns.
The facility failed to meet care plan requirements, including the absence of key IDT members in meetings, delayed care plan meetings, and outdated care plans. These deficiencies affected residents with conditions like edema, fall risks, and mental health issues, as their care plans lacked necessary interventions and updates.
A resident with a broken bottom front tooth did not receive timely dental services due to the facility's failure to follow standard procedures. Despite the resident's request for a dental referral upon admission, no referral order was placed in the medical record, and transportation staff were not informed. The resident was only scheduled for a routine dental appointment later in the year, highlighting a lapse in care coordination.
A facility failed to provide a resident and their representative with written notifications of hospital transfers, omitting essential information such as contact details for the Ombudsman and appeal rights. The facility did not document or send transfer notices, as confirmed by staff interviews and the Ombudsman.
A facility failed to provide a resident and their representative with a written notice of the bed hold policy during hospitalizations. The resident was transferred to the hospital twice, and the facility did not document the duration for which the bed would be held or provide the necessary notification. Interviews revealed inconsistencies in procedures, with outdated forms being used and a lack of clarity regarding bed hold days for residents with specific payment sources.
A facility failed to finalize a resident's annual MDS assessment within the required 7-day period. The assessment, with an ARD in early October, was not signed off by the MDS/RN Coordinator until late November and was only marked as export ready for transmission the following day. This delay could likely lead to staff being unaware of the resident's current status and needs.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential misinterpretations of their needs. One resident was incorrectly noted as unable to communicate pain, despite being cognitively intact and able to express pain levels. Another resident's MDS inaccurately documented anticoagulant use, which was not prescribed. A third resident was also misassessed regarding communication abilities, despite being able to verbally express pain.
A long-term care facility failed to meet professional standards of quality care for four residents due to medication management issues. Two residents did not receive their prescribed medications because they were unavailable, and the facility did not notify the physician or document communication with the pharmacy. Another resident received partial doses of insulin and refused trazodone without the physician being informed. Additionally, a resident did not receive Ditropan due to unavailability, and the staff failed to contact the pharmacy or notify the physician.
A facility failed to develop an individualized discharge plan for a resident, which is crucial for a safe transition to the post-discharge setting. The resident's medical record lacked documentation of discharge goals, needs, summary, recapitulation of stay, and medications. The DON confirmed the absence of these records during an interview.
A facility failed to complete a discharge summary for a resident discharged to their home. The resident's EMR lacked a recapitulation of stay, medication list, and discharge summary. The DON confirmed that the staff did not complete the necessary documentation at the time of discharge, and there was no evidence that a discharge summary was provided to the resident.
A resident in the facility expressed a need for hearing aids and had an appointment a year ago but never received them. Despite informing staff multiple times, no action was taken to address the issue. A review of the resident's records showed no documentation of any intervention or audiologist appointment. Staff interviews confirmed the resident's need was communicated, but no appointment was scheduled.
The facility failed to inform two residents of changes to their smoking privileges, resulting in confusion and dissatisfaction. One resident, cognitively intact, was unaware of the smoking schedule and expressed frustration over not being able to keep smoking items. Another resident, with moderate cognitive impairment, was not informed of the changes in smoking rules. The smoking schedule was not posted, and staff were unaware of the correct smoking times.
The facility failed to implement proper infection control measures for residents diagnosed with COVID-19 in the D Unit. Staff wore N95 masks but did not use other PPE, and there were no precaution signs or accessible PPE outside residents' rooms. Interviews revealed inconsistencies in infection control practices, with staff unaware of which residents were under COVID-19 precautions. The facility did not follow its COVID protocols or CDC guidelines, potentially risking the spread of infection.
A facility failed to develop an accurate baseline care plan within 48 hours of admission for a resident, which is essential for immediate care. The resident had specific physician's orders for a bland diet, fluid restrictions, and Jevity 1.2 via a peg tube, along with water flushes before and after medication. However, these interventions were not included in the baseline care plan, an omission confirmed by the DON.
The facility failed to complete a comprehensive MDS within 14 days for a resident admitted on [DATE]. The assessment was still in progress and not completed by 05/08/24, as confirmed by an LPN.
A facility failed to complete a baseline care plan within 48 hours of admission for a resident, omitting critical medications such as Seroquel, Sertraline, and Xanax. This was confirmed by an LPN during an interview.
A resident with Parkinson's disease did not receive their prescribed Sinemet medication on time due to an emergency situation that delayed the morning dose. This led to the omission of the 12:00 PM dose, contrary to the physician's orders and the resident's care plan.
Failure to Provide Appropriate Behavioral Health Services
Penalty
Summary
The facility failed to ensure residents with diagnosed mental health disorders, psychosocial distress, and suicidal ideation received appropriate behavioral health treatment and services for three residents reviewed for behavioral-emotional health. The deficiencies involved failure to provide or obtain psychotherapy/counseling for one resident with PTSD, major depressive disorder, anxiety, and suicidal thoughts; failure to notify the PMHNP of another resident’s hallucinations; and failure to follow through with psychiatric referral/consultation for a third resident with multiple psychiatric diagnoses and repeated suicidal ideation. One resident was admitted with PTSD, major depressive disorder, and anxiety disorder. The record showed a psychotropic evaluation listing music and psychotherapy as non-pharmacologic care, and the care plan noted the resident had PTSD and had the potential to plan on ending his life because of pain and did not want to continue. Progress notes documented that the resident said he was struggling with pain and did not want to carry on, and staff wrote they would schedule a psych appointment so he could talk about depression and suicidal thoughts. During interview, the resident stated he was very depressed, did not want to go on, had accepted counseling, but no one ever showed up for the counseling sessions. He stated the Chaplain visited occasionally but was not qualified or useful for the help he needed, and he needed a psychiatric therapist trained in PTSD. The Chaplain stated he provided spiritual and emotional assistance, but did not have formal mental health training or formal training for treating PTSD. The NP stated she provided counseling only if the resident complained of issues, did not have consistent counseling sessions with the resident, and the record did not contain documentation that she provided counseling. Another resident was admitted with bipolar disorder. A progress note documented the resident reported moles in his room and under his covers, and CNA interview confirmed the resident had been seeing moles for a couple of months and that the nurse was told. The CNA stated housekeeping would go into the room, shake the sheets, and tell the resident the moles were gone. The NP stated she was not aware the resident saw moles and would have discussed medication changes with the provider if she had known. The record did not contain other psychotropic evaluations after an earlier evaluation, did not document hallucinations or delusions on the MDS, did not include hallucinations on the care plan, and did not contain referrals for a psychiatric consult. The third resident had diagnoses including major depressive disorder, paranoid schizophrenia, unspecified dementia, generalized anxiety disorder, and suicidal ideation. The record contained repeated crisis hotline calls, statements that the resident was depressed, wanted to die, or had been looking for an alternative to suicide, and multiple requests to see a psychiatrist or be transferred for psychiatric care. The resident also reported that the facility’s mental health treatment was not working and that he wanted to see an actual psychiatrist. Social services notes documented that the resident appeared to be hallucinating about God, was lonely, isolated, and not receiving the psychiatric care he needed. The provider notes showed plans to evaluate him by psychiatry or place referrals, but the medical record did not document that he was seen by a psychiatrist or that psychotherapy notes were present. The PMHNP stated she saw the resident only when issues arose or when nurses raised concerns, and the facility leadership confirmed the facility did not have a psychiatrist and that the resident wanted to see one.
Inadequate Mental Health Services for Residents
Penalty
Summary
The facility failed to provide adequate mental health services for two residents, R #62 and R #70, who were reviewed for mental health. R #62, who was admitted with diagnoses including Bipolar Disorder, Depression, Dementia, and PTSD, reported not receiving any behavioral health services since admission. Despite expressing feelings of depression and hopelessness, there was no documentation of a psychiatric consultation or evaluation by a psychiatric professional. The care plan for R #62 lacked interventions for his mental health diagnoses beyond medication administration and monitoring for side effects. R #62's medical records did not include orders for behavior monitoring or the effectiveness of prescribed medication for his mental health conditions. Interviews with staff revealed that the facility did not have a psychiatric provider or counselor, and interventions were limited to medication and occasional visits from a chaplain. The Director of Nursing confirmed the absence of a psychiatric referral and evaluation, and the care plan did not address all of R #62's mental health diagnoses. Similarly, R #70, who was admitted to hospice, expressed a wish to die and showed increased emotional distress. Despite these signs, there was no documentation of social services being provided, and the facility relied on hospice's assessment of the emotional state as part of the disease process. The facility's chaplain, who lacked a social work degree, was the primary source of emotional support, and the Director of Nursing acknowledged the lack of mental health care for R #70.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination for one resident who was not allowed to leave the facility independently, despite having a contract that permitted independent travel. The resident, who was cognitively intact with a BIMS score of 15, expressed a desire to leave the facility on his own, particularly to attend church on Sundays. Despite his insistence and the existence of an Independent Travel Contract approved by the Interdisciplinary Care Team, the facility staff repeatedly informed him that he could not leave without staff supervision due to safety concerns. The resident's progress notes indicate multiple instances where he was reminded of the facility's policy requiring staff accompaniment when leaving the campus. The resident consistently asserted his right to leave independently, referencing his travel contract. Social services and nursing staff documented their attempts to communicate the facility's policy and safety concerns to the resident, as well as efforts to involve the resident's family in addressing the issue. However, the resident maintained his stance, leading to a deficiency in honoring his right to self-determination.
Deficiencies in Care Plan Development and Revision
Penalty
Summary
The facility failed to ensure that care plan requirements were met for several residents, leading to deficiencies in the care provided. For multiple residents, the required Interdisciplinary Team (IDT) members did not participate in care plan meetings. This included the absence of key personnel such as the Director of Nursing (DON) or Assistant Director of Nursing (ADON), and the physician or medical director was not invited to these meetings. This lack of comprehensive team involvement could result in incomplete care plans that do not fully address the residents' needs. Additionally, the facility did not hold a care plan meeting within the required seven days of completing the admission Minimum Data Set (MDS) assessment for one resident. This delay in care planning could lead to a lack of timely interventions and adjustments to the resident's care, potentially impacting their health and well-being. The facility also failed to revise care plans with the most current resident information for several residents. For instance, one resident's care plan did not reflect their edema condition or the interventions in place to manage it, such as the use of compression stockings and medication. Another resident's care plan did not document actual falls or the necessary interventions to prevent future falls. Furthermore, a resident with mental health diagnoses did not have a care plan that included all relevant diagnoses or non-pharmacological interventions, such as involving the Chaplain or social worker when showing signs of depression.
Failure to Schedule Dental Services for Resident with Broken Tooth
Penalty
Summary
The facility failed to ensure that a resident, identified as R #62, received necessary dental services for a broken tooth. Upon admission, R #62 informed the staff about a broken bottom front tooth and expressed a desire to see a dentist. Despite this, no action was taken to schedule a dental appointment. A review of R #62's nursing progress notes from March 2024 indicated that the resident reported the cracked tooth and requested a dental referral, but no referral order was placed in the medical record. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the standard procedure was not followed. The LPN acknowledged that a referral order should have been entered into the resident's medical record, and transportation should have been notified to schedule the appointment. However, the transportation staff was unaware of the issue and had only scheduled R #62 for a routine annual dental appointment later in December 2024. The DON confirmed that the staff failed to enter the necessary referral order for the resident to see a dentist.
Failure to Provide Transfer Notifications and Appeal Rights
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding transfers to the hospital. The resident, who had trouble breathing and experienced a fall, was transferred to the hospital on two occasions. However, the facility did not provide the resident or their representative with written transfer notices, nor did they include necessary information such as the contact details for the Office of the State Long-Term Care Ombudsman or the resident's appeal rights. Additionally, the facility did not send a copy of the transfer notices to the Ombudsman. Interviews with staff, including an LPN and the DON, revealed that the facility did not have a process in place to complete or provide transfer notifications before or after hospital transfers. The staff did not document the required information in the resident's medical record or provide the resident with a transfer assessment. The Ombudsman confirmed that no transfer notices were received from the facility, indicating a systemic issue in the facility's notification process.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to a resident and their representative during instances of hospitalization. The resident, identified as R #12, was transferred to the hospital on two occasions, once for abnormal laboratory results and another time after hitting his head during a fall. In both instances, the facility did not document the duration for which the bed would be held, nor did they provide the resident or his representative with the necessary written notification of the bed hold policy. The forms used by the facility lacked spaces to document the number of days the bed would be held, and there was no evidence that the resident or his representative received the notification. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed inconsistencies in the facility's procedures. The LPN stated that nurses were responsible for completing a Bed-Hold Authorization & Agreement form and discussing the policy with alert residents. However, the DON confirmed that the Bed-Hold Authorization & Agreement form was outdated and should not have been used. Additionally, the facility's bed hold policy did not specify that residents with certain payment sources, such as the Veterans Administration, had an unlimited number of bed hold days. This information was not included in the notifications provided to the resident, leading to a lack of clarity and proper documentation regarding the bed hold policy for R #12.
Delayed Finalization of MDS Assessment
Penalty
Summary
The facility failed to ensure the timely finalization of the annual Minimum Data Set (MDS) assessment for one resident, which was not transmitted and accepted within the required 7-day period. Specifically, the resident's annual MDS assessment had an Assessment Reference Date (ARD) of October 10, 2024, but the MDS/RN Coordinator did not sign off on the assessment until November 20, 2024. Furthermore, the assessment was only marked as export ready for electronic transmission on November 21, 2024. This delay in finalizing the MDS assessment could likely lead to staff being unaware of the resident's current status and needs.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could result in an inaccurate understanding of their needs. For one resident, the MDS assessment indicated that a pain assessment interview was not conducted because the resident was rarely or never understood, despite the resident having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness and the ability to communicate pain levels verbally. This discrepancy was confirmed by an LPN who stated that the resident had no issues with communication. Another resident's quarterly MDS assessment inaccurately documented the use of an anticoagulant, which was not supported by the physician's orders. The Director of Nursing confirmed that the resident did not take anticoagulant medication. Additionally, a third resident's admission MDS assessment also failed to conduct a pain assessment interview due to the assumption of communication difficulties, despite the resident having a moderate cognitive impairment and being able to verbally communicate pain levels, as confirmed by an LPN.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents due to several medication-related issues. For two residents, the facility did not notify the physician when medications were unavailable. Resident #18 did not receive amitriptyline for neuropathy on multiple occasions in August 2024 because the medication was not available, and there was no documentation of the pharmacy being contacted or the physician being notified. Similarly, Resident #48 did not receive metolazone for edema on several days in November 2024, and again, there was no documentation of communication with the pharmacy or physician. Additionally, the facility failed to administer medications according to physician's orders for two residents. Resident #51 received only partial doses of insulin glargine on multiple occasions in October and November 2024, and there was no documentation of the physician being informed of these partial doses. Furthermore, Resident #51 refused trazodone on numerous occasions in November 2024, but the staff did not notify the physician of these refusals. Lastly, Resident #87 did not receive Ditropan for bladder control on several days in November 2024 due to the medication being unavailable. The staff documented the unavailability but did not contact the pharmacy or notify the physician. The Director of Nursing confirmed that staff should have contacted the pharmacy and documented their communication in the resident's progress notes.
Failure to Develop Individualized Discharge Plan
Penalty
Summary
The facility failed to develop an individualized discharge plan for a resident, which is necessary to ensure a safe transition from the facility to the resident's post-discharge setting. The resident was discharged on 09/27/24, but a review of the medical record revealed that the staff did not document a discharge plan, including the resident's discharge goals and needs. Additionally, the discharge summary, recapitulation of stay, and medications were not recorded in the resident's medical record. During an interview on 11/21/24, the Director of Nursing (DON) confirmed that the discharge goals or needs were not documented in the resident's charts.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for a resident who was discharged to their home. The resident's Electronic Medical Record (EMR) lacked a recapitulation of the resident's stay, a medication list, and a discharge summary. During an interview, the Director of Nursing (DON) confirmed that the staff did not complete the discharge summary at the time of the resident's discharge. The DON also acknowledged that the staff should have completed and signed the resident's recapitulation of stay on the same day as the discharge. There was no documentation indicating that a discharge summary was provided to the resident.
Failure to Provide Hearing Aids to Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing, which could compromise their quality of life. The resident expressed a need for hearing aids and mentioned having an appointment a year ago but never received the aids or any follow-up information. Despite informing staff multiple times about the need for hearing aids, no action was taken to address the issue. A review of the resident's progress notes and medical records revealed no documentation of any intervention by staff to obtain hearing aids or refer the resident for an audiologist appointment. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that the resident's need for hearing aids was communicated, but no appointment was scheduled. The DON stated that the protocol involved staff informing transportation to schedule appointments, but this was not done for the resident in question.
Failure to Inform Residents of Smoking Policy Changes
Penalty
Summary
The facility failed to ensure that residents were adequately informed of changes to their rights regarding smoking privileges. Two residents, one with a cognitive impairment and another cognitively intact, were not made aware of the smoking schedule or the locations where they could smoke. The facility's smoking policy, which states that smoking is a privilege and not a right, was not effectively communicated to these residents. One resident expressed frustration over not being able to keep their smoking items and not being informed of the smoking schedule, while the other resident was unaware of the changes in smoking rules and did not have a copy of the smoking schedule. The facility's documentation revealed inconsistencies, such as a signed smoking policy in one resident's medical record but not in the other's. Additionally, the smoking schedule was not posted in the housing units, and staff members, including a CNA, were unaware of the correct smoking times. The Director of Nursing confirmed that the smoking policy had changed earlier in the year, but the communication of these changes to residents was inadequate, leading to confusion and dissatisfaction among the residents.
Inadequate Infection Control Measures for COVID-19 in D Unit
Penalty
Summary
The facility failed to maintain proper infection prevention measures for residents diagnosed with COVID-19, particularly in the D Unit. Observations revealed that staff wore N95 masks but did not utilize other necessary personal protective equipment (PPE) such as gowns, gloves, or face shields. Additionally, there were no transmission-based precaution signs on residents' doors, and PPE was not readily accessible outside of residents' rooms but was instead located in a secured staff area away from resident care areas. Residents in common areas were not wearing masks, and staff did not enforce mask-wearing among residents. Interviews with various staff members, including a CNA, the Director of Nursing (DON), and the Infection Control Coordinator, highlighted inconsistencies and gaps in the facility's infection control practices. The DON and QAPI nurse were responsible for infection prevention and control, yet they did not ensure that proper precautions were in place, such as placing signs or PPE outside the rooms of residents diagnosed with COVID-19. The Infection Control Coordinator was unaware of which residents were recently cleared from COVID-19 precautions, indicating a lack of communication and tracking within the facility. The facility's COVID protocols and CDC guidelines were not adequately followed. The protocols required that residents with COVID-19 be quarantined and that staff wear appropriate PPE, including gowns and gloves, when interacting with infected residents. However, these measures were not implemented, and staff were not adequately informed or trained on the necessary precautions. The failure to adhere to these protocols and guidelines likely contributed to the potential spread of infection within the facility, affecting all residents on the D Unit.
Failure to Develop Accurate Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for a resident, identified as R #8, which is necessary to properly care for them immediately upon their admission. The record review revealed that R #8 was admitted to the facility on an unspecified date and had specific physician's orders dated 09/06/24 and 09/07/24, which included a bland diet, no food by mouth, fluid restrictions, and Jevity 1.2 at 65 ml per hour via a peg tube, along with a requirement to flush 30 ml of water before and after medication administration. However, the baseline care plan dated 09/07/24 did not include interventions for the peg tube, such as the water flush and Jevity feeding. This oversight was confirmed during an interview with the Director of Nursing (DON) on 09/11/24, who acknowledged the omission in the baseline care plan.
Failure to Complete MDS Assessment Within 14 Days of Admission
Penalty
Summary
The facility failed to ensure a comprehensive Minimum Data Set (MDS) was completed within 14 calendar days after admission for one of the residents reviewed. Specifically, the resident was admitted on [DATE], but the Admission MDS assessment was still in progress and not completed by 05/08/24. This was confirmed during an interview with an LPN on 05/08/24 at 4:05 PM, who acknowledged that the assessment had not been completed within the required timeframe.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident, which is necessary to provide effective and person-centered care. The resident was admitted to the facility and had physician's orders for Seroquel, Sertraline, and Xanax. However, the baseline care plan created on the same day of admission did not include these medications. This omission was confirmed during an interview with an LPN, who acknowledged that the medications were ordered upon admission but were not included in the baseline care plan as required.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for a resident diagnosed with Parkinson's disease. The resident was prescribed Sinemet 25-100 mg to be taken four times a day at specific times. However, on one occasion, the medication was not administered at the scheduled 12:00 PM time due to the morning dose being given late at 11:20 AM. This delay was caused by an emergency situation where the nurse had to send another resident to the hospital, resulting in the inability to administer the subsequent dose on time. The resident's care plan specifically indicated the need to administer medications as ordered and to monitor and document the effectiveness and side effects. Despite this, the Medication Administration Record (MAR) showed a missed dose, and the nurse's note confirmed the delay and subsequent omission of the 12:00 PM dose. This failure to administer the medication as scheduled could potentially impact the therapeutic effects of the treatment for the resident's Parkinson's disease.
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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 Truth Or Consequences
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paloma Springs Healthcare Llc | 1.4 mi | ★★★★★ | 4 | 0 |
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