Mescalero Care Center: Medication Safety Failures - NM
The dangerous reading was just one of at least 15 times between April and May that staff at Mescalero Care Center administered blood pressure medication to the resident despite readings above 180 systolic or below 50 pulse — all violations of the physician's explicit instructions to call when those thresholds were crossed.
Federal inspectors found the facility failed to meet professional standards of care during a May 19 inspection, documenting a pattern of nurses ignoring medical orders and performing treatments without proper authorization.
The blood pressure case involved a resident admitted with essential hypertension who was prescribed Amlodipine with specific parameters: hold the medication and call the doctor if systolic pressure exceeded 180, diastolic exceeded 100, or pulse dropped below 50. Instead, nurses documented giving the medication while recording dangerous vital signs.
On April 1, staff gave the medication after documenting blood pressure at 195/63. On April 5, they administered it with a reading of 181/64. On April 8, they gave it twice despite pulse readings of 47 and 43 — both well below the 50 threshold requiring a physician call.
The pattern continued into May. Staff gave medication on May 11 with a blood pressure reading of 217/92, on May 5 with 198/74, and on May 15 with 215/74. Progress notes showed no documentation that physicians were ever notified of the elevated readings or low pulse rates.
"Facility staff did not call the physician as indicated on the order and staff are expected to follow the physician's order," the Director of Nursing confirmed to inspectors.
In a separate case, nurses performed wound care on a resident's right leg for weeks without any physician orders. The resident told inspectors she had cellulitis in both legs, with the right leg "worse than her left." She said nurses were performing wound care on both legs and she was taking antibiotics.
A registered nurse confirmed to inspectors that she performed wound care on both legs, washing wounds with saline solution, applying non-adhesive dressing, and wrapping with kerlix bandages. But medical records showed orders only existed for left leg wound care.
"Staff were expected to get orders for wound care for the right leg prior to performing wound care on the right leg," the Director of Nursing told inspectors.
The violations extended beyond medication and wound care. Staff failed to update care plans when residents' conditions changed, leaving critical safety measures undocumented.
One resident with dementia and a history of falls had physician orders for a fall mat next to her bed and the bed in the lowest position. But during two separate observations on May 12 and May 13, inspectors found the resident in bed with the fall mat folded up next to the bathroom instead of beside the bed where ordered.
"Staff were expected to put the fall mat next to her bed when she was in bed," the Director of Nursing confirmed.
Care plan failures affected multiple residents. One resident refused showers 11 out of 23 times they were offered between February and May, but her care plan was never updated to include strategies for encouraging bathing. Another resident fell in April and required increased monitoring and redirection as interventions, but these measures were never added to her care plan.
The facility also failed to provide required physician visits. Four residents hadn't seen a doctor within the required 60-day timeframe, with one resident going from July 2024 to April 2025 without a physician visit — a span of more than eight months.
Medication management problems extended to psychiatric drugs. The facility's consultant pharmacist recommended dose reductions for multiple residents taking antidepressants and anti-anxiety medications, but physicians declined without providing required patient-specific rationales.
One resident had been taking sertraline for anxiety since September 2024 when the pharmacist recommended a dose reduction in March 2025. The medical director marked "disagree" and "resident with good response, maintain current dose" but provided no specific justification for continuing the medication at the same level.
Another resident was taking four different psychiatric medications — sertraline, trazodone, escitalopram, and hydroxyzine — when the pharmacist recommended dose reductions. The medical director declined all recommendations without providing the required patient-specific rationales for why the medications needed to continue unchanged.
Staff training failures compounded the care problems. Three of five nursing staff members sampled had not completed required training in effective communication, resident rights, or quality assurance programs. One registered nurse hadn't completed abuse and neglect training since December 2023, despite annual requirements.
The facility's dietary operations lacked proper oversight. The home had operated without a certified dietary manager for over a month at the time of inspection, with the administrator confirming no qualified manager had been in place since April 18.
Food safety violations were documented in the nutrition room, where inspectors found expired sandwiches and cheese in the refrigerator, along with frozen sandwiches stored improperly in refrigerated conditions without expiration dates. Staff admitted they weren't checking refrigerator and freezer temperatures as required.
Activity programming fell short for residents with specific preferences. One resident told inspectors she wasn't offered activities in her room and would like prayer, bible study, music, games, or crafts. "No one comes in and watches tv with me, no talking or conversing," she said. Records showed no documentation of spiritual, music, or reading activities for her personal preferences over three months.
Dental care delays affected multiple residents. One resident said she needed dentures checked because they were loose but hadn't seen a dentist since admission months earlier. Another resident's family reported a dental filling fell out six months prior, with progress notes confirming the broken filling in November 2024, but no dental visit had occurred by the time of inspection.
Medical record keeping failures created additional risks. Staff documented giving pain medication to one resident 12 times over six weeks but failed to record the location of pain or whether the medication was effective in most instances. Only one entry noted "throat pain" — the rest provided no context for why pain medication was needed.
The facility serves 29 residents in the small community of Mescalero, home to the Mescalero Apache Tribe. The May inspection found violations across multiple areas of care, from basic medication safety to specialized services like wound care and psychiatric treatment.
The Director of Nursing acknowledged most of the violations during inspector interviews, confirming that staff had not followed physician orders for blood pressure monitoring, had not obtained proper wound care orders, and had not updated care plans as required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mescalero Care Center from 2025-05-19 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
Mescalero Care Center in Mescalero, NM was cited for violations during a health inspection on May 19, 2025.
Instead, nurses documented giving the medication while recording dangerous vital signs.
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.