Cycle 1
Health 2024-11-15 · Fire 2024-11-15
25 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rio Rancho, NM
The Suites Rio Vista
2-star overall rating with 2-star inspections with $93,914 in total fines with 25 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2410 19th Street SE, Rio Rancho, NM
(505) 452-4200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
136
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
2015-01-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,955
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9884
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.58
Baseline 23.26% · Performance 20.09% · Measure score 4.58 · Achievement 2.89 · Improvement 4.58
Healthcare-associated infections
7.21
Baseline 10.17% · Performance 6.18% · Measure score 7.21 · Achievement 5.54 · Improvement 7.21
Total nurse turnover
1.60
Baseline 65.52% · Performance 57.14% · Measure score 1.60 · Achievement 1.60 · Improvement 1.56
Adjusted total nurse staffing
0.39
Baseline 2.97 hours · Performance 3.22 hours · Measure score 0.39 · Achievement 0 · Improvement 0.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.23% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 7.6% · Lower 95% interval 6.13% |
| Discharge to community | 57% |
50.57%
6.4 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 51.01% · Lower 95% interval 49.8% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 133 · Denominator 133 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 133 |
| Discharge self-care score | 49.32% |
53.69%
4.4 pts worse
|
Numerator 36 · Denominator 73 |
| Discharge mobility score | 53.42% |
50.94%
2.5 pts better
|
Numerator 39 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 0.75% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 133 · Adjusted rate 0.68% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 4.96% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | 34.71% |
8.2%
26.5 pts better
|
Numerator 42 · Denominator 121 |
| Staff flu vaccination coverage | 45.74% |
42%
3.7 pts better
|
Numerator 59 · Denominator 129 |
| Discharge function score | 57.53% |
56.45%
1.1 pts better
|
Numerator 42 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 107 · Denominator 107 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.15% |
25.2%
5.9 pts better
|
Numerator 19 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.6
1.7 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.6
0.2 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.4%
2.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.7%
1.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.5%
1.5 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.6% · Q3 3.2% · Q4 1.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.8%
1.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.4%
4 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.9% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.8% |
14.1%
15.7 pts worse
|
19.6%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.1% · Q2 37.0% · Q3 20.4% · Q4 17.3% · 4Q avg 29.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
14.7%
8.7 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.6% · Q3 7.3% · Q4 7.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.7% |
15.8%
9.1 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 0.0% · Q3 4.2% · Q4 6.6% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
14.6%
8.4 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 1.9% · Q3 8.3% · Q4 4.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.3%
0.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
0.9%
2.7 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.8% · Q3 0.0% · Q4 3.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
20.6%
10.5 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 12.8% · Q3 5.4% · Q4 0.0% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.7%
1 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.4% · Q3 8.3% · Q4 7.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.6%
13.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
15.9%
5 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
86.4%
13.1 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
21.3%
3.6 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 26.8% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-11 · Fire 2023-12-11
22 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-31 · Fire 2022-08-31
39 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-02-02
F · Potential for more than minimal harm
2022-08-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-11-05
D · Potential for more than minimal harm
2025-08-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-05
E · Potential for more than minimal harm
2025-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-17
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-04-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-02-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-14
F · Potential for more than minimal harm
2024-11-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-07-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-01-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-12-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-11
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-02-02
G · Actual harm
2023-05-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-05-05
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-05
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-05
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-13
E · Potential for more than minimal harm
2023-04-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-04-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-04-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-13
H · Actual harm
2022-08-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-11
G · Actual harm
2022-08-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-11
G · Actual harm
2022-08-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-11
F · Potential for more than minimal harm
2022-08-31
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-10-11
F · Potential for more than minimal harm
2022-08-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-11
E · Potential for more than minimal harm
2022-08-31
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-31
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-10-11
C · Minimal harm
2022-08-31
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-10-11
Penalties and ownership
What sits behind the stars
$93,914
2023-04-04
Fine
Fine · fine $93,914
Fine
Ownership
Eduro Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Bewsey, Michael
5% Or Greater Indirect Ownership Interest · Individual
Ramos, Brian
5% Or Greater Indirect Ownership Interest · Individual
Eduro Healthcare LLC
Operational/Managerial Control · Organization
Thompson, Christopher
Corporate Officer · Individual
Thompson, Christopher
W-2 Managing Employee · Individual
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