Silver City Care Center: Death Prank on Staff - NM
The nursing assistant nudged the resident. She was cold. Dead.
When she left the room to alert staff, the registered nurse was standing outside laughing. He told her it was a "cruel rookie joke" and asked her not to say anything because he wanted to play the same prank on another employee.
The nursing assistant had a panic attack so severe that emergency medical services were called to check her out.
Federal inspectors found that Silver City Care Center failed to protect residents from mistreatment and neglect when staff used a deceased resident's body as the centerpiece of a workplace prank. The violation triggered immediate jeopardy sanctions — the most serious level of enforcement action — during a January 28 inspection.
The registered nurse had originally planned to send a different staff member into the deceased resident's room as a "friendly joke," according to a written statement from a certified medication aide. When that employee didn't show up for work, the nursing assistant became the target instead.
Resident 16 had died during the night at 10:56 a.m., but the administrator wasn't at the facility when it happened. She learned the next morning that the registered nurse had sent the nursing assistant to check vital signs on the deceased resident.
Initially, the administrator believed it was a teaching opportunity.
"The Administrator said RN #1 used the passing of R #16 as a teaching opportunity to teach NA #1 what to do when a resident passes," inspectors wrote.
The administrator found the nursing assistant passing meal trays later that day. The worker became upset, started breathing heavily, and said she'd had a rough morning. An ambulance was called to examine her, and she went home for the day.
The administrator didn't report the incident to state authorities because she "thought it was a staff thing."
The truth emerged only after the nursing assistant's family member sent an email to the administrator, explaining that sending the worker to check on the deceased resident had been a joke. Only then did the administrator begin an investigation.
The nursing assistant never returned phone calls during the investigation. She couldn't be interviewed.
The registered nurse also avoided accountability. He didn't answer three phone calls from inspectors and never returned voicemails. He remained working at the facility until after the inspection, despite being placed on administrative leave pending investigation.
The administrator's written reprimand to the registered nurse focused on his poor judgment in pranking an inexperienced employee, not on the mistreatment of a deceased resident. The performance improvement plan stated he was disciplined for "sending NA #1 to get vitals on a deceased resident [due to NA #1 being inexperienced]."
No mention of dignity violations. No acknowledgment that using a dead resident's body for entertainment was inappropriate.
"The Administrator confirmed that there was not any education or correction provided for RN #1 or other staff regarding respecting deceased residents," inspectors found. "The Administrator never acknowledged that the prank was inappropriate."
The administrator told inspectors she didn't understand how the incident affected Resident 16 "because she was already deceased." She confirmed the incident wasn't reported as a staff-to-resident violation for that reason.
The facility's investigation file contained no written statement from the director of nursing. The administrator didn't document the DON's involvement in the incident or oversight of the registered nurse and other staff involved.
The administrator served as the facility's abuse coordinator, responsible for investigating allegations of mistreatment. Her own undated written statement, created as part of the internal investigation, confirmed that the nursing assistant told her "a joke had been played on her when RN #1 sent her into the resident's room do vitals on a dead lady."
Federal inspectors called immediate jeopardy on January 28 at 4:55 p.m.
The facility's corporate leadership took control. Market-level administrators provided emergency oversight while the local administrator and director of nursing were placed on administrative leave for additional training on abuse investigations and federal definitions of neglect.
A senior operations resource lead assumed the role of abuse coordinator. Market clinical advisors began reviewing all investigations to ensure completeness.
The company conducted a full audit from late January through early February, interviewing alert residents about whether they felt treated with dignity. For residents unable to respond, staff called family members and guardians with the same questions.
No new allegations emerged.
The registered nurse was placed on administrative leave pending investigation, with his last scheduled work day occurring after the inspection. The facility implemented a policy requiring immediate removal of any staff member involved in abuse allegations.
Corporate leadership re-educated the administrator and director of nursing on resident abuse and neglect policies, emphasizing dignity, respect, and proper reporting procedures. Market-level staff assumed oversight of facility operations and clinical care.
The immediate jeopardy designation was lifted after the facility submitted its plan of removal, but the violation remained. Inspectors verified implementation of corrective measures through staff interviews, policy reviews, and training documentation.
The nursing assistant who discovered Resident 16's body never returned to work at Silver City Care Center. The registered nurse who orchestrated the prank avoided investigators' attempts to interview him about using a deceased resident to terrorize a coworker.
The administrator who failed to recognize the violation of human dignity in her facility continued to maintain that a dead resident couldn't be mistreated.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Silver City Care Center from 2025-01-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
Silver City Care Center in Silver City, NM was cited for immediate jeopardy violations during a health inspection on January 28, 2025.
The nursing assistant nudged the resident.
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.