FORT BAYARD MEDICAL CENTER

Nursing Home Inspector

41 FORT BAYARD ROAD
SANTA CLARA, NM 88026
Grant County
Phone: 575-537-8604
Provider Number: 325120
Last Inspection: 06/20/2017

About the Nursing Home

Number of Beds: 200
Number of Residents: 124
Beds Available: 76
Percent Occupancy: 62%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Government - State
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

32

Facility
45

County
37

NM
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

32

2017
15

2016
16

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/20/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Widespread : Potential 4 7/10/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 7/14/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 7/20/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Immediate 6 7/20/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 7/14/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 7/14/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Actual 4 7/14/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 7/14/2017
 

3/4/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 5/5/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 5/5/2016
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 5/5/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 5/5/2016
 

4/17/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 6/10/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 6/10/2015
 
Failed To: Hire sufficient dietary support personnel. Pattern : Minimal 4 6/10/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/10/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/24/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Pattern : Minimal 4 8/31/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 9/15/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 9/15/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 9/15/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 8/31/2016
 

10/29/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 1/8/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 1/8/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 1/8/2016
 

2/25/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 3/2/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 3/2/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NM State Avg
Number of Residents 124 97.50 77.72
Registered Nurses 1.24 0.98 0.82
Licensed Practical / Vocational Nurses 0.21 0.24 0.49
Certified Nursing Assistants 4.07 3.31 2.18
Total Staff Hours 5.51 4.54 3.50

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NM State Avg%
of high risk long-stay residents with pressure ulcers 7 4 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 92 84
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 88 92
of long-stay residents experiencing one or more falls with major injury 1 2 3
of long-stay residents who have depressive symptoms 5 3 4
of long-stay residents who lose too much weight 6 3 7
of long-stay residents who received an antianxiety or hypnotic medication 19 20 18
of long-stay residents who received an antipsychotic medication 26 20 16
of long-stay residents who self-report moderate to severe pain 12 13 10
of long-stay residents who were physically restrained 8 5 0
of long-stay residents whose ability to move independently worsened 7 21 21
of long-stay residents whose need for help with daily activities has increased 12 20 18
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 9 5 3
of low risk long-stay residents who lose control of their bowels or bladder 28 33 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 80 81 69
of short-stay residents who had an outpatient emergency department visit 10 12 13
of short-stay residents who made improvements in function 72 66 64
of short-stay residents who newly received an antipsychotic medication 1 0 2
of short-stay residents who self-report moderate to severe pain 36 33 23
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 72 71 69
of short-stay residents who were rehospitalized after a nursing home admission 8 9 20
of short-stay residents who were successfully discharged to the community 66 62 53
of short-stay residents with pressure ulcers that are new or worsened 1 1 1