Manzano Del Sol: Fall Investigation Never Done - NM
No investigation was opened. No follow-up report was sent to state regulators. When inspectors arrived months later and asked the Director of Nursing why, she gave an answer that was both honest and alarming: the resident never came back, so she hadn't bothered.
That explanation, offered during an August 7 interview, is now at the center of a federal inspection finding against the Albuquerque facility.
Resident 77 was admitted to Manzano Del Sol on June 20, 2025. The admission diagnoses alone describe a person with serious vulnerabilities: cardiomyopathy, Type 2 diabetes, unspecified dementia, hypoxemia, and atherosclerotic heart disease. Within four days of arriving, something went wrong.
On June 24, the resident fell. Then fell again the same evening. The facility's own incident report, filed that day, did not record the times of either fall. What it did record was that Resident 77 had complained of pain — and that the pain turned out to have a cause. The resident had fractured the neck of the right femur, the bone just below the ball of the right hip joint. A femoral neck fracture is among the most serious injuries an older adult can sustain, carrying significant risks of complications, surgical intervention, and permanent loss of mobility.
The resident was discharged to the hospital. The facility's electronic health record contains no documentation that anyone at Manzano Del Sol ever investigated how those falls happened, why they happened twice in one evening, or what, if anything, could have prevented them.
The Director of Nursing told inspectors she was aware that a Five Day Follow-Up Report — a formal account of the facility's investigation into the incident, required to be submitted to the State Survey Agency within five days of an incident report — was due. She knew the deadline. She did not meet it. She explained that because Resident 77 had been hospitalized and did not return to the facility, she had not completed the investigation.
That reasoning is worth sitting with for a moment. The facility's position, as stated by its own nursing director, was that a resident who fell twice, broke their hip, and left for the hospital was therefore no longer worth investigating.
The Five Day Report requirement exists precisely because the state cannot independently verify whether residents are safe from neglect without knowing what a facility found when it looked into its own incidents. When no report arrives, regulators are left without the information they need to determine whether something systemic failed — a staffing gap, a fall-prevention breakdown, an assessment that was missed. In this case, that determination was never made possible, because the investigation was never done.
Inspectors found no evidence in the health record that the facility had examined the circumstances of either fall or the resulting fracture. The incident report itself was thin: two falls, no times recorded, a pain complaint, a diagnosis. Nothing more.
Manzano Del Sol's handling of this case cuts against the basic logic of incident reporting. Facilities are required to investigate and report not only to protect the resident involved, but because patterns of falls, of injuries, of gaps in supervision, only become visible when investigations are actually completed and submitted. A resident who leaves for the hospital is not a closed case. The facility's obligation to understand what happened does not end at the door.
The inspection that surfaced this finding was a complaint investigation, concluded August 11, 2025. The level of harm was assessed as minimal harm or potential for actual harm — the lower end of the federal scale. But the rating reflects the regulatory category of the violation, not the severity of what happened to Resident 77. A broken hip is not a minor event for a person with dementia, heart disease, and low blood oxygen. The consequences of that injury, and whatever contributed to those two falls, belong in a record somewhere. Right now, they are not.
What inspectors documented was a narrow but clear failure: one resident, one incident, one required report that was never filed, one investigation that was never started. The Director of Nursing did not dispute any of this. She confirmed it.
There is something clarifying about that candor. This was not a case where the facility claimed the paperwork had been filed and inspectors found it missing. The DON told inspectors directly that she had not completed the investigation. Her reason — that the resident left — suggests either that the obligation was misunderstood, or that the facility's internal accountability systems did not flag the missing report in the weeks between the June 24 incident and the August inspection.
Resident 77 had been at Manzano Del Sol for four days when the falls occurred. Four days after a June 20 admission, a person with dementia and multiple cardiac conditions fell twice in one evening and fractured their hip. Whether the falls were related to their diagnoses, to their environment, to their medications, to their level of supervision in those first days after admission — none of that was ever examined, at least not in any record that inspectors could find.
The state agency, under the inspection framework, cannot assure the safety of residents when facilities do not complete and submit their follow-up reports. That language, from the inspection finding itself, is careful and bureaucratic. What it means in practice is simpler: the people responsible for oversight were kept in the dark, not by deception, but by inaction.
Resident 77 did not return to Manzano Del Sol after being hospitalized. Whatever happened next — whether the resident recovered, where they went, what the hip fracture ultimately cost them — is not in this record. The inspection report ends where the facility's accountability did: at the hospital door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manzano Del Sol By Purehealth from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 8, 2026 · Our methodology
Manzano Del Sol by Purehealth in Albuquerque, NM was cited for violations during a health inspection on August 11, 2025.
No follow-up report was sent to state regulators.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.