C+
69/100Fort Bayard Medical Center Inspection Report, Violations & Safety Grade (Santa Clara, New Mexico)
41 Fort Bayard Road, Santa Clara, New Mexico 88026
Phone: 5755373302
CMS Overall:3/5
Overview & Bed Count
Certified Beds
200
Avg Residents/Day
134.6
Ownership
Government - State
Provider Type
Medicare and Medicaid
County
Grant
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health2/5
Staffing5/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | New Mexico Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.05 | 0.65 | +0.40 |
| Total Nurse Hours per Resident per Day | 5.77 | 3.58 | +2.19 |
| CMS Staffing Rating | 5/5 | 2.8/5 | - |
| Nursing Staff Turnover | 37.6% | 53.5% | - |
Health Citation History
63 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-13 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2026-08-13 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2026-08-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2026-08-13 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | D – Moderate Harm Potential |
| 2026-08-13 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-04-08 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-11-17 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2025-11-17 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2025-11-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | E – Moderate Harm Potential |
| 2025-11-17 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2025-11-17 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2025-11-17 | Quality of Life and Care Deficiencies | Assist a resident in gaining access to vision and hearing services. | E – Moderate Harm Potential |
| 2025-11-17 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E – Moderate Harm Potential |
| 2025-11-17 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-11-17 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-11-17 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | E – Moderate Harm Potential |
| 2025-11-17 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2025-11-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2025-11-17 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-11-17 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-11-17 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-11-17 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-11-17 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-11-17 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | D – Moderate Harm Potential |
| 2025-11-17 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-11-17 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2025-11-17 | Infection Control Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-07-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E – Moderate Harm Potential |
| 2025-07-10 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2025-07-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2025-07-10 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-01-24 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2025-01-24 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-08-09 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | F – Moderate Harm Potential |
| 2024-08-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2024-08-09 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2024-08-09 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-08-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | E – Moderate Harm Potential |
| 2024-08-09 | Quality of Life and Care Deficiencies | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | E – Moderate Harm Potential |
| 2024-08-09 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2024-08-09 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-08-09 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D – Moderate Harm Potential |
| 2024-08-09 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2024-08-09 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-08-09 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-06-11 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-06-11 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | H – Actual Harm |
| 2024-06-11 | Resident Assessment and Care Planning Deficiencies | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | E – Moderate Harm Potential |
| 2024-06-11 | Nursing and Physician Services Deficiencies | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | E – Moderate Harm Potential |
| 2024-06-11 | Resident Assessment and Care Planning Deficiencies | Plan the resident's discharge to meet the resident's goals and needs. | D – Moderate Harm Potential |
Showing 50 of 63 citations.
Fire Safety Citation History
44 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-11-17 | Emergency Preparedness Deficiencies | Address patient/client population and determine types of services needed. | F – Moderate Harm Potential |
| 2025-11-17 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | F – Moderate Harm Potential |
| 2025-11-17 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | F – Moderate Harm Potential |
| 2025-11-17 | Emergency Preparedness Deficiencies | Provide emergency officials' contact information. | F – Moderate Harm Potential |
| 2025-11-17 | Emergency Preparedness Deficiencies | Provide a means of sharing information on occupancy/needs. | F – Moderate Harm Potential |
| 2025-11-17 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-11-17 | Construction Deficiencies | Meet other general requirements. | F – Moderate Harm Potential |
| 2025-11-17 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | F – Moderate Harm Potential |
| 2025-11-17 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2025-11-17 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | F – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | F – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | F – Moderate Harm Potential |
| 2025-11-17 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-11-17 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | F – Moderate Harm Potential |
| 2025-11-17 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2025-11-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | F – Moderate Harm Potential |
| 2025-11-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-11-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | F – Moderate Harm Potential |
| 2025-11-17 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2025-11-17 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2025-11-17 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | E – Moderate Harm Potential |
| 2025-11-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | E – Moderate Harm Potential |
| 2025-11-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2025-11-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2025-11-17 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2025-11-17 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
| 2024-08-09 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2024-08-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-08-09 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2024-08-09 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-06-01 | Emergency Preparedness Deficiencies | Address patient/client population and determine types of services needed. | F – Moderate Harm Potential |
| 2023-06-01 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | F – Moderate Harm Potential |
| 2023-06-01 | Emergency Preparedness Deficiencies | Provide a means of sharing information on occupancy/needs. | F – Moderate Harm Potential |
| 2023-06-01 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2023-06-01 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-06-01 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-06-01 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
Total Penalties & Fines
$83,501
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-06-11 | Fine | $83,501 | - |
| 2024-06-11 | Payment Denial | - | 13 days starting 2024-07-13 |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Santa Clara area at no cost.
Find Safe, Vetted Facilities Near Santa Clara
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.