The resident, identified as R #16 in inspection documents, had fractured his left fibula and received sutures and staples to close wounds from the open fracture. On December 3, physicians ordered facility staff to remove the sutures and staples from his left leg.
Staff never followed through.
The sutures remained in the resident's leg for nearly three weeks. On December 23, an outside wound care clinic removed the sutures and staples that facility staff should have taken out 20 days earlier.
During a December 30 interview with federal inspectors, the facility's Director of Nursing confirmed the timeline. She acknowledged that staff had received the December 3 physician's order to remove the resident's sutures and staples. She confirmed that staff failed to carry out the order until the wound clinic intervened on December 23.
The Director of Nursing told inspectors that staff were expected to follow physician's orders. She said staff should have removed the resident's sutures and staples as directed.
The resident had been admitted to Betty Dare Wellness with a diagnosis of a fractured left fibula. Medical records described it as an open fracture type 1 or 2, indicating a small wound with minimal contamination, and noted the fracture was healing routinely without complications.
Federal inspectors found the facility failed to meet professional standards of practice for wound care. The inspection report noted that when facilities don't provide care according to physician orders, residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving prescribed treatment.
Sutures and staples are designed to be removed within a specific timeframe as wounds heal. Leaving them in too long can lead to complications including infection, scarring, and tissue damage. The timing of suture removal is particularly critical for elderly residents whose healing processes may already be compromised.
The violation occurred during a complaint inspection conducted on December 30. Inspectors reviewed records for three residents but found the suture removal failure affected only one person.
Betty Dare Wellness & Rehabilitation operates at 3101 North Florida Avenue in Alamogordo. The facility is required to provide services that meet professional standards of quality care for all residents.
The inspection report classified the violation as causing minimal harm or potential for actual harm to the resident. However, the 20-day delay in removing sutures from a healing fracture site represents a clear breakdown in basic medical care protocols.
Staff at nursing facilities are routinely trained to follow physician orders precisely and document completion of medical procedures. The failure to remove sutures as ordered suggests gaps in either staff training, supervision, or documentation systems at Betty Dare Wellness.
The resident's case illustrates how seemingly routine medical procedures can be overlooked in nursing home settings, potentially compromising resident health outcomes. While the resident's fracture was noted as healing routinely, the prolonged presence of sutures could have introduced unnecessary risks.
The facility must now develop and implement a plan of correction to address the deficiency and prevent similar incidents. Federal regulations require nursing homes to ensure all services meet professional standards and that physician orders are followed promptly and accurately.
For the resident whose sutures were left in place for 20 days, the delayed removal meant enduring weeks of unnecessary medical hardware in his healing leg, waiting for care that should have been provided when his doctor ordered it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Betty Dare Wellness & Rehabilitation LLC from 2025-12-30 including all violations, facility responses, and corrective action plans.