Silver City Care Center: Nurse's Death Prank - NM
The incident at Silver City Care Center involved Resident 16, who died at 10:56 PM after staff performed CPR and called 911. Hours later, Registered Nurse 1 instructed Nursing Assistant 1 to take the deceased resident's vital signs.
"NA #1 stated when she went into R #16's room, the room was cold," inspectors wrote. "NA #1 said R #16 would usually respond to her right away when entering the room. NA #1 said R #16's dentures did not seem to be sitting right in her mouth."
The aide nudged the resident and realized she was cold and had died. When she left the room to alert staff, she found the night manager "standing outside the room laughing."
"RN #1 said it was a cruel rookie joke that he was playing and RN #1 told NA #1 not to say anything because he wanted to play the joke on another staff member," according to the inspection report.
The nursing aide became so distressed that emergency medical services had to be called to evaluate her for a panic attack.
Federal inspectors cited Silver City Care Center for immediate jeopardy violations after discovering that administrators failed to recognize the incident as resident mistreatment. The facility's response treated it as a training issue rather than abuse of a deceased person still under their care.
Administrator Beverly Baca, who serves as the facility's abuse coordinator, told inspectors she "did not report the incident to the state because she thought it was a staff thing." She characterized the nurse's actions as using the death "as a teaching opportunity to teach NA #1 what to do when someone passes away."
The administrator only began investigating after receiving an email from the nursing aide's family member days later, describing what had actually happened.
Resident 16 had died during the night shift after staff found her unresponsive with weak pulse and inadequate breathing. Progress notes show staff initiated a code blue, performed CPR, and called 911, but paramedics were unable to revive her.
The nursing aide arrived for her morning shift at 6:00 AM and noticed the deceased resident's door was closed, which she said was unusual. At 6:30 AM, the night shift manager told her to check vital signs on the resident.
"NA #1 stated she nudged R #16 and noticed at that time she was cold. NA #1 stated she realized R #16 had passed, so she left the room to let staff know," inspectors documented.
The facility's written reprimand to the nurse focused only on sending staff to check vitals on a deceased resident. It made no mention of disrespecting the dead person or using her body for entertainment.
"The policy violation was RN #1 should not have told NA #1 to do vitals on a dead resident," the performance improvement plan stated. "It states that NA #1 could not handle it and that some people cannot handle, especially a young person that has not dealt with death before."
The facility's abuse prohibition policy requires suspected abuse to be reported immediately and employees alleged to have committed abuse to be removed from duty pending investigation. Neither happened initially.
The registered nurse continued working at the facility until investigators arrived, receiving only a written reprimand. He was eventually placed on administrative leave after federal inspectors called immediate jeopardy, but only after being scheduled for days off following the incident.
During the investigation, administrators attempted to reframe the incident as a postmortem care issue. The facility's follow-up report claimed they investigated whether proper care was provided after death, focusing on whether dentures were properly handled rather than addressing the prank itself.
"An investigation was started and the NOC (night) shift were interviewed about the post mortem care done for [Name of R #16] after she passed away on the NOC shift," the facility's report stated.
Staff who provided postmortem care said they removed the resident's dentures and placed them in a denture cup to be sent with the body. But this missed the central issue: a staff member had used the deceased person's body to frighten a coworker.
Administrator Baca told inspectors she "did not believe that there was any effect to R #16 because she was already deceased when it happened." She confirmed there was no education provided to staff about respecting deceased residents.
The facility's investigation focused on whether dentures were properly positioned rather than the fundamental violation of human dignity. Even after the immediate jeopardy citation, the facility's corrective actions emphasized reporting procedures and staff training rather than addressing the dehumanization of residents.
Inspectors made three attempts to interview the registered nurse involved, leaving voicemails that were never returned.
Federal inspectors found additional violations during their investigation, including failures to provide basic care like regular showers and teeth brushing for residents who needed assistance. Three residents received significantly fewer baths than scheduled, with one getting only one shower in December despite being scheduled for twice weekly.
One resident who depended entirely on staff for oral care had his teeth brushed only two times during December day shifts, though night staff were more consistent. When inspectors interviewed him, "R #17's breath smelled horrible" and he confirmed staff did not brush his teeth regularly.
The facility also failed to follow physician orders for monitoring an underweight resident's weekly weights and properly administering insulin to diabetic residents. Staff frequently held insulin doses without notifying doctors as required, even when blood sugar levels were above the parameters specified in medical orders.
After immediate jeopardy was called, the facility submitted a removal plan that included re-educating administrators about abuse reporting, interviewing residents and families about potential mistreatment, and placing the nurse on administrative leave.
But the fundamental question remained unanswered: how administrators could witness a staff member using a deceased resident's body to terrorize a coworker and classify it as anything other than profound disrespect for human dignity, even in death.
The nursing aide who discovered the body continued to suffer the consequences of what her supervisor called his "cruel rookie joke," while administrators spent weeks investigating denture placement instead of confronting the dehumanization that had occurred under their watch.
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 incident at Silver City Care Center involved Resident 16, who died at 10:56 PM after staff performed CPR and called 911.
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.