Home / New Mexico / Truth Or Consequences
New Mexico State Veterans Home
992 South Broadway, Truth Or Consequences, NM 87901 · Sierra County · (575) 894-4200
131 certified beds, about 126 residents a day · Government - State · Medicare and Medicaid since 1994
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
3 of 5
Staffing
3 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 325092 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on May 14, 2026, inspectors cited 22 health deficiencies (the New Mexico average is 17.9, the national average 9.2).
Of 60 health citations since August 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 2 fines totaling $128,954 in the last three years; the largest was $84,728, and the latest is dated May 14, 2026.
Nurses and nurse aides worked 6.02 hours per resident per day, against 3.54 across New Mexico and 3.86 nationally. Registered nurses accounted for 0.53 of those hours.
84.1% of nursing staff left within the year CMS measured (New Mexico average 53.3%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1708/23
305/24
209/24
1312/24
2205/26
307/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 60 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
2H
0I
Potential for more than minimal harm
31D
24E
1F
Potential for minimal harm
0A
0B
2C
July 15, 2026Complaint inspection · 3 citations
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview, observation, and record review the facility failed to ensure care plan revisions occurred for 3 (R #16, R #17, and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for falls, when staff failed to revise resident care plans with the most current interventions to prevent falls or injury. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure medical records were complete and accurate for 2 (R #17 and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for falls when staff failed to: 1. Ensure staff documented who attended IDT meetings, what was discussed, and what decisions were made regarding R #17 and R #18's care after falls. 2. Accurately document placement of R #18's fall mat. These deficient practices could likely cause residents to not have the equipment needed to prevent injury and cause staff to not have the most accurate resident information adversely impacting the care staff provides.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #18) of 3 (R #16, R #17, R #18) residents reviewed for falls, when staff failed to: 1. Implement a systems approach to evaluate fall hazards and identify interventions to prevent future falls for R #18. 2. Ensure R #18 had a fall mat next to his bed while R #18 was in bed as ordered by the provider. These deficient practices could likely result in an increased risk of residents falling or getting injured if they fall.
May 14, 2026Standard inspection, Complaint inspection · 22 citations
- H Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents with diagnosed mental health disorders, psychosocial distress, and/or suicidal ideation received appropriate behavioral health treatment and services for 3 (R #5, R #89, and R #131) of 4 (R #5, R #9, R #89, and R #131) residents reviewed for behavioral-emotional health, when the facility failed to provide or obtain psychotherapy/counseling for R #5 and R #131; failed to notify the Psychiatric Mental Health Nurse Practitioner (PMHNP) of R #89's hallucinations; and failed to follow through with psychiatric referral/consultation for R #131. [...]
- E Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 ( R #11, and R #78) of 5 (R #2, R #6, R #11, R #78, and R #124) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure antipsychotic medications (a class of psychotropic medication primarily used to manage psychosis, a mental health symptom involving a loss of contact with reality, characterized by hallucinations, delusions, and disorganized thinking) were prescribed to treat an appropriate psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior) for R #78. 2. Ensure a gradual dose reduction (GDR; [...]
- E Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS was accurate for 3 (R #1, R #9 and R #133) of 6 (R #1, R #7, R #9, R #112, R #132, and R #133) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 9 (R #2, R #4, R #5, R #11, R #18, R #28, R #29, R #92, and R #124 ) of 9 (R #2, R #4, R #5, R #11, R #18, R #28, R #29, R #92, and R #124) residents reviewed for care plans, when the staff failed to: 1. Ensure the required IDT members attend the care plan meeting, and staff did not document any input from the physician or the CNA who provided care for R #2, R #4, R #5, R #11, R #18, R #28, R #29, and R #92. 2. Ensure the care plan meeting was held within 7 days from the completion of the MDS assessment when creating or revising the care plan for R #4, R #28, and R #29. 3. Revise the care plan with the most current resident information for R #1, R #2, R #5, and R #124. [...]
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation in a timely manner for 3 (R #6, R #11, R #78) of 5 (R #2, R #6, R #11, R #78, and R #124) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects and residents receiving medications that are no longer necessary.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to store food under sanitary conditions for all 127 residents who eat food from the kitchen (residents were identified by the resident Matrix provided by the Administrator on 04/20/26), when they failed to label and date food items in the receiving kitchen refrigerator. If the facility fails to store food under safe and sanitary conditions then this could likely lead to foodborne illnesses (Foodborne illness can occur if you eat foods that are contaminated with harmful pathogens such as bacteria, viruses, and fungi) in residents.
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 5 (R #7, R #9, R #10, R #58, and R #112) of 6 (R #7, R #9, R #10, R #58, R #112, and R #133) residents reviewed for accuracy of documentation, when staff failed to: 1. Ensure the Preadmission Screening and Resident Review (PASRR, a mandatory federal program requiring Medicaid-certified nursing facilities to screen all applicants for serious mental illness and intellectual/developmental disabilities) included all mental health diagnoses for R #7 and R #112. 2. [...]
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (R #124) of 1 (R #124) residents randomly sampled, when the staff failed to interact and explain to R #124 why they were in House 2. This deficient practice could likely result in residents feeling embarrassed, angry, and that their feelings are unimportant to the facility staff.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #2) of 5 (R #2, R #6, R #11, R #78, and R #124) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, this deficient practice could likely result in residents and/or their representatives not being able to make informed decisions regarding residents' care.
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to provide the required transfer information for 1 (R #1) of 2 (R #1 and R #128) residents reviewed for hospitalizations when staff failed send a copy of the written notice of transfer to the Ombudsman. This deficient practice could likely result in the residents and/or their representatives not receiving assistance from the ombudsman in the transition from the nursing home.
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #132) of 2 (R #28 and R #132) residents reviewed for MDS timing. This deficient practice could likely result in residents' needs not being met.
- D Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure that an MDS assessment was completed every three months for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments when they failed to complete a quarterly MDS assessment within 92 days of the previous assessment reference date (ARD; the specific end point for the look-back periods in the MDS assessment process, also called the observation or assessment period.). This deficient practice could result in residents' assessments being outdated and residents not receiving care and treatment that meets their current needs.
- D Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to complete and transmit a MDS assessment within 14 days of completion (sign off by RN) for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments. This deficient practice could lead to the facility not reporting information in a timely manner (within 14 days) to the federal agency.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #132) of 4 (R #1, R #9, R #132, R #133) residents reviewed for medical care, when staff failed to implement an order after a doctor visit. This deficient practice could likely lead to unnecessary discomfort, prolonged symptoms or worsening of medical conditions.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 2 (R #2, and R #5) of 4 (R #1, R #2, R #5, and R #29) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression.
- D Provide appropriate foot care.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide foot care for 1 (R #87) of 4 (R #1, R #11, R #78, and R #87) resident reviewed for Activities of Daily Living (ADL) care when staff failed to provide nail care for R #87's toenails. This deficient practice could likely cause residents to have podiatric complications (foot and toenail health issues such as ingrown toenails, fungal infections, and trauma-related injuries).
- D 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.
Inspectors wroteBased on observation, record review, and interview, the facility failed to properly store medications for 2 (R #46 and R #85) of 2 (R #46 and R #85) residents randomly sampled for medication storage, when staff failed to ensure medications were not expired in treatment cabinet for R #46, and R #85. This deficient practice could likely result in residents obtaining medications not prescribed to residents, and that are no longer effective, resulting in adverse side effects.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program for 1 (R #107) of 2 (R #9 and R #107) residents reviewed for Transmission Based Precautions (additional infection control measures used in healthcare settings alongside Standard Precautions. They prevent the spread of known or suspected pathogens) when staff failed to follow enhanced barrier precautions (EBP, an infection control intervention) for R #107. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were educated on and offered the influenza (Flu: highly contagious respiratory illness caused by the influenza viruses that infection the nose, throat and sometimes the lungs leading to mild and potentially severe illness) and pneumococcal (moderate to highly contagious respiratory illness caused by bacteria that infect the nose throat and sometimes the lungs and can lead to severe illness such as pneumonia) immunizations and ensure that residents who completed and signed a consent form received the vaccination for 2 (R #112, R #132) of 5 (R #2, R #28, R #112, R #124, and R #132) residents reviewed for immunizations. [...]
- D Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough, capable of progressing to severe symptoms and in some cases death) vaccinations to 2 (R #2 and R #132) of 5 (R #2, R #28, R #112, R #124, and R #132) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents having a higher likelihood of contracting COVID-19 and spreading the infection to other residents in the facility.
- C Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on interview and observation, the facility failed to post the most recent state survey results in areas of the facility that were in a prominent and accessible location for residents and the public. This could affect all 128 residents in the facility (residents were identified by the Census Report provided by the Administrator on 04/13/26). If residents are unable to locate the latest survey conducted by the State Surveyors, then residents, representatives, and visitors are likely unable to know how the facility is doing and make decisions accordingly.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to publicly post nurse staffing data on a daily basis, this has the potential to affect all 128 residents (residents were identified by the census list provided by the Medical Records Director on 04/13/26), when staff failed to post required staffing information. This deficient practice could likely prevent residents and the public from having access to accurate current and previous staffing records.
December 27, 2024Standard inspection, Complaint inspection · 13 citations
- H Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on record review and interview, the facility failed to provide adequate mental health services for 2 (R #62 and R #70) of 2 (R #62 and R #70) residents reviewed for mental health. This deficient practice likely resulted increased depression, hopelessness and psychosocial distress for R #62 and R #70.
- E Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review, the facility failed to promote resident self-determination (the ability to make your own choices and decisions without being controlled by others) for 1 (R #18) of 3 (R #18, R #69 and R #256) residents reviewed for choices when staff did not allow the resident to go out into the community on their own. If the facility is not honoring resident's choices, then residents are likely to feel a loss of independence and self-worth leading to feelings of frustration and depression.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure care plan requirements were met for 11 (R #4, R #6, R #18, R #48, R #49, R #51, R #57, R #62, R #78, R #87 and R #256) of 14 (R #4, R #6, R #18, R #48, R #49, R #51, R #57, R #62, R #69, R #73, R #76, R #78, R #87 and R #256) residents reviewed for care plans when they failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #4, R #6, R #18, R #51, R #57, R #78, and R #87. 2. Ensure the care plan meeting was held within seven days of completion of the admission Minimum Data Set Assessment (MDS; [...]
- E Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents obtained dental services for 1 (R #62) of 1 (R #62) residents sampled for dental services, when staff failed to schedule dental services for R#62's broken tooth. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition and/or appearance of teeth, and potential dental or oral complications.
- D Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on record interview, observation, and record review, the facility failed to ensure residents were aware of changes to their rights for 2 (R #69 and R #256) of 3 (R #48, R #69 and R #256) resident reviewed for smoking. If the facility does not inform residents of their rights, then residents are likely to be unaware of their rights offered at the facility.
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative of a transfer in writing for 1 (R #12) of 1 (R #12) residents sampled for hospitalizations when they failed to: 1. Notify the resident or the resident's representative of the transfers to the hospital in writing and in a language and manner they understand. 2. Ensure the contents of the notice included the following: -The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form. -Statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. [...]
- D Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #12) of 1 (R #12) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.
- D Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review the facility failed to ensure the annual Minimum Data Set assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was finalized (transmitted and accepted) within 7 days for 1 (R #25) of 4 (R #18, R #25, R #51 and R #87) residents reviewed for MDS assessments. If MDS assessments are not finalized in a timely manner, it could likely lead to staff being unaware of resident's current status and needs.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 3 (R #18, R #69 and R #256) of 6 (R #18, R #51, R #69, R #76, R #87, and R #256) residents reviewed for accurate MDS assessments. These deficient practices could likely result in the facility not having an accurate assessment of the resident's needs.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to meet professional standards of quality for 4 (R #18, R #48, R #51 and R #87) of 4 (R #18, R #48, R #51 and R #87) residents when staff failed to: 1. Notify the physician when medication was not available for R #18 and R #48. 2. Administer medications according to physician's orders for R #51 and R #87. 3. Notify the physician when R #51 refused medication. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician.
- D Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review, the facility failed to develop the resident's individualized discharge goals and needs for 1 (R #100) of 1 (R #100) resident reviewed for discharge planning. This deficient practice is likely to prevent a safe transition from the facility to the resident's post-discharge setting.
- D Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff completed a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) and a reconciliation of all medication at the time of discharge for 1 (R #100) of 1 (R #100) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility, community agency, or family member not knowing what the current care needs and/or current medications are for the resident.
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received proper treatment to maintain hearing for 1 (R #78) of 3 (R #69, R #73, and R #78) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot hear, which would compromise their quality of life.
September 10, 2024Complaint inspection · 2 citations
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures when they failed to initiate transmission-based precautions (used to prevent the spread of infectious agents from individuals who are suspected to be infected, such as gloves, facemasks, and gowns) for residents diagnosed with COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Failure to adhere to an infection control program is likely to cause the spread of infections and illness to all 12 residents on the D Unit (residents were identified by the resident matrix provided by Administration on 09/09/24).
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (a document with the minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #8) of 3 (R #8, R #9, and R #10) residents reviewed for resident neglect. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (an undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.
May 8, 2024Complaint inspection · 3 citations
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was completed within 14 calendar days after admission for 1 (R #1) of 4 (R #1, R #2, R #31, and R #32) residents reviewed. This deficient practice could likely result in residents' preferences and care needs not being met.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission, that includes the instructions needed to provide effective and person-centered care to residents for 1 (R #1) of 5 (R #1, R #2, R #3, R #31, and R #32) residents reviewed for Care Plans. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #2) of 2 (R #1 and R #2) residents reviewed for medication administration. This deficient practice is likely to result in a resident failing to obtain therapeutic effects of medication treatment or worsening of condition.
August 25, 2023Standard inspection · 17 citations
- F Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on record review and interview the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 53 residents (residents were identified by the resident matrix as provided by the Administrator on 08/21/23). This deficient practice could likely affect direct patient care and limit residents' abilities to obtain the best possible care while in the facility.
- E Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to ensure that residents and representatives were informed of and participate in their treatment for 2 (R #2, R #33) of 2 (R #2, and R #33) residents reviewed for documentation, when: 1) R #2 or R #2's power of Attorney (POA) did not sign the MOST form (advanced directive), and 2) Consent for R #33's medications was not obtained. These deficient practices could like result in residents or their representatives not being able to participate in their treatment or make their own decisions.
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive assessment (complete assessment that includes not only the traditional care of the resident, but also the prevention and early detection of disease and rehabilitation) was completed and accurate for 2 (R #33, and R #35) of 3 (R #6, R #33, and R #35) residents reviewed for completion of a comprehensive MDS assessment. When they failed to: 1. Include R #33's diagnosis of PTSD (Post Traumatic Stress Disorder; mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), and 2. Complete the pain management section of the MDS assessment for R #35. This deficient practice could likely result in residents' preferences and needs not being met.
- E Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure that 19 (R #1, R #3, R #5, R #7, R #10, R #12, R #13, R #15, R #17, R #19, R #20, R #22, R #23, R #24, R #28, R #32, R #38, R #39, R #40) of 19 (R #1, R #3, R #5, R #7, R #10, R #12, R #13, R #15, R #17, R #19, R #20, R #22, R #23, R #24, R #28, R #32, R #38, R #39, R #40) residents reviewed for Minimum Data Set assessments, have MDS documents completed, and finalized in a timely manner. If MDS assessments are not completed and finalized in a timely manner, it could likely cause residents to receive less than optimal care.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 3 (R #18, R #25 and R #35) of 7 (R #1, R #6, R #18, R #25, R #33, R #35 and R #191) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 2 (R #35 and R #242) of 6 (R #1, R #6, R #33, R #35, R #191 and R #242) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions.
- E Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care that meets professional standards for 1 (R #1) of 1 (R #1) resident sampled for limited range of motion, when they failed to use neck support and wedge (are used for trunk stabilization to maintain positioning) for proper positioning. This deficient practice could likely result in worsening of resident's trunk control (ability to control your upper body [trunk or torso]) or unnecessary pain and discomfort.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received care and treatment in accordance with professional standards of care (reasonable degree of care a person should provide to another person, typically in a professional or medical setting) for 1 (R #35) of 2 (R #35 and R #191) reviewed for hospitalizations by: Not continuing antibiotic orders for continued treatment of Pneumonia for R #35 as per hospital discharge instructions resulting in rehospitalization for Pneumonia. These deficient practices could likely lead to unnecessary pain, suffering, hospitalization, and death.
- E Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were receiving rehabilitative services, PT (Physical therapy is the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), OT (Occupational therapy is a form of therapy that encourages rehabilitation through the performance of activities required in daily life), and ST (Speech therapy is a form of therapy to improve speaking and swallowing, enabling clients to regain/retain their independence following the debilitating effects of illness or injury.) services as ordered by the physician for 1 (R #241) of 1 (R #241) resident reviewed for rehab services. This deficient practice is likely to result in a decrease in resident's functional mobility.
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure that the physician reviewed and addressed pharmacy recommendations for 2 (R #25 and R #35) of 5 (R #8, R #18, R #25, R #33, and R #35) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).
- E Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive antipsychotic (drug primarily used to treat psychotic disorders such as schizophrenia [mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior. that impairs daily functioning]) medications unless the medication is necessary to treat a specific condition or diagnosis and is documented in the medical record for 1 (R #33) of 5 (R #8, R #18, R #25, R #33, and R #35) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a clinical indication (medical reason) and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less when medications were given late or not given at all for 3 (R #5, R #6, and R #242) of 12 (R #5, R #6, R #8, R #14, R #16, R #23, R #24, R #27, R #91, R #92, R #242 and R #243) residents observed during medication pass. Resulting in a medication error rate of 28.21%. This deficient practice could likely result in residents being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).
- E Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on record review and interview, the facility failed to provide food that accommodates resident preferences for 7 (R #2, R #8, R #20, R #34, R #35, R #91 and R #244) of 7 (R #2, R #8, R #20, R #34, R #35, R #91, and R #244) resident's reviewed for food preferences. This deficient practice is likely to result in the resident having less than optimal nutritional health outcomes and resident food preferences not being honored.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (R #23) of 1 (R #23) residents randomly sampled, when the facility failed to ensure staff are not removing resident's personal property without their knowledge, This deficient practices are likely to result in residents feeling angry, and that their feelings and preferences are unimportant to the facility staff.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on interview and record review, the facility failed to reasonably accommodate residents needs for 1(R #35) of 2 (R #1 and R #35) reviewed for medical appointments. If the facility is not honoring resident's preferences and/or requests for medical appointments the resident may feel like their preferences and requests are being ignored and lead to feeling like their needs do not matter.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to notify the physician for 1 (R #191) of 2 (R #35 and R #191) residents reviewed for hospitalization, when they failed to notify R #191's physician about her abdominal pain, fever, or low blood pressure. This deficient practices could likely result in residents not receiving necessary care or delay in treatment if the Physician is not notified of new or worsening symptoms.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that 1 (R #14) of 3 (R #14, R #23, and R #36) residents reviewed for behavioral-emotional health were receiving necessary behavioral health care to meet their needs. This deficient practice likely resulted in R #14 experiencing prolonged symptoms including depression (persistent feeling of sadness and loss of interest), paranoia (unjustified mistrust of other people and their actions) thoughts and hallucinations (perception of something not present).
Fire safety inspections
4 fire safety citations on file: 3 on August 25, 2023, 1 on June 15, 2022.
Every fire safety citation4 citations
- F Address patient/client population and determine types of services needed.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- E Have simulated fire drills held at unexpected times.
- F Have simulated fire drills held at unexpected times.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 14, 2026 | Fine | $84,728 |
| May 14, 2026 | Payment Denial | 23 days from June 5, 2026 |
| December 27, 2024 | Fine | $44,226 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | New Mexico | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 6.02 | 3.54 | 3.86 |
| Registered nurses | 0.53 | 0.63 | 0.69 |
| All nursing staff on weekends | 5.50 | 3.10 | 3.42 |
| Nurse aides | 4.47 | ||
| Licensed practical nurses | 1.03 | ||
| Nursing staff turnover (share who left in a year) | 84.1% | 53.3% | 45.8% |
| Registered nurse turnover | 66.7% | 53.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.61 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 6.24 on weekdays and 5.50 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 75.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.68 in April to June 2025 to 6.02 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 6.02 | 0.53 | 6.24 | 5.50 | 75.6% | 0 of 90 | 126 |
| Oct to Dec 2025 | 5.98 | 0.41 | 6.19 | 5.45 | 76.3% | 0 of 92 | 129 |
| Jul to Sep 2025 | 5.98 | 0.38 | 6.20 | 5.44 | 72.1% | 0 of 92 | 124 |
| Apr to Jun 2025 | 5.68 | 0.30 | 5.83 | 5.29 | 70.5% | 0 of 91 | 123 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| New Mexico, Jan to Mar 2026 | 3.52 | 0.60 | 3.69 | 3.10 | 14.2% | 1.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | New Mexico | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.7 | 11.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.1 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.6 | 0.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.5 | 3.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 6.5 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.6 | 11.7 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.0 | 5.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 21.6 | 14.5 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.8 | 1.8 |
Owners and operators
Legal business name: STATE OF NEW MEXICO.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| State of New Mexico | Operational/managerial control | Organization | 11/01/2024 | |
| Hatley, Brent | Operational/managerial control | Individual | 01/01/2025 | |
| Shull, Kenneth | Operational/managerial control | Individual | 01/01/2025 | |
| State of New Mexico | Trustee of the SNF | Organization | 11/01/2024 | |
| State of New Mexico | Adp of the SNF | Organization | 09/17/2025 | |
| Shull, Kenneth | Adp of the SNF | Individual | 07/23/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 23 problems in this area, most recently on July 15, 2026: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 12 problems in this area, most recently on May 14, 2026: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 10 problems in this area, most recently on July 15, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on May 14, 2026: "Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures."
Other nursing homes nearby
- Paloma Springs Healthcare LLC T Or C, 1.4 mi · 4 of 5 stars · 41 citations
New Mexico contacts for a concern about a nursing home
These are the official offices in New Mexico. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: New Mexico Health Care Authority, Division of Health Improvement, Health Facility Licensing and Certification, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: New Mexico Long-Term Care Ombudsman Program, Aging and Long-Term Services Department, 866-451-2901. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
Common questions
- What is New Mexico State Veterans Home's Medicare star rating?
- CMS rates New Mexico State Veterans Home 3 out of 5 stars overall, with 3 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did New Mexico State Veterans Home get at its last inspection?
- 22 health deficiencies at the standard inspection on May 14, 2026. The New Mexico average is 17.9.
- Has New Mexico State Veterans Home been fined?
- Yes. CMS lists 2 fines totaling $128,954 in the last three years.
- Does New Mexico State Veterans Home accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns New Mexico State Veterans Home?
- CMS lists 6 owners and managers. Legal business name: STATE OF NEW MEXICO.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.