Calibre Post Acute, Llc

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the facility's Diabetic Management Policy. L. On 10/17/25 at 11:00 AM, during an interview, the DON confirmed the following: 1. Staff did not contact the provider to notify them of R #1's and R #2's low BP readings and holding BP medications. 2. Staff did not contact the provider to notify them of R #9's blood sugar levels as indicated in the order or the facility's Diabetic Management Policy. 3. Her expectation is that if staff have concerns regarding resident's vital signs and deciding to hold medications, they should contact

the provider, document the conversation held with provider and enter a new order as needed depending on what the provider's decision is regarding the medication. 4. Staff should contact the physician as stated on

the physician's orders. 5. Staff should follow facility's policy regarding contacting the provider.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm

#26 did confirm R #24 is on Duloxetine (antidepressant medication). LPN #26 stated for R #24 there's no documentation regarding suicidal ideations in R #24's MAR. LPN #26 stated if the order in the MAR doesn't state to monitor and provide interventions for suicidal thoughts and suicidal behaviors then the nurses won't document. LPN #26 did confirm that if the medication has a black box warning the nurses are to look at that and it should be put in the MAR to monitor the resident.

Residents Affected - Some R. On 10/10/25 at 1:54 PM during an interview with the DON regarding R #24's antidepressant medication black box warnings; the DON confirmed R #24 had no documentation and was not being monitored for suicidal ideations on the R #24's MAR. The DON stated that suicidal behaviors for the black box warning for Duloxetine has increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients, and R #24 is not in either of these categories. The DON stated that her expectation is that the nurses will assess the residents and keep communication with the physician and inform the CNAs to assist in monitoring residents and for the nurses to document appropriately for each residents' black box warning.

S. On 10/14/25 at 12:29 PM, during an interview, the Medical Director confirmed the following:

1. 1. Oxcarbazepine is an anti-convulsant medication and is not approved to be prescribed for the diagnosis of

depression.

2. 2. A GDR for antidepressant medications should be attempted if a resident is not showing signs of

depression.

3. 3. Providers are expected to document a clinical rationale for why a GDR should not be attempted.
4. 4. All residents who are being treated with antidepressant medications should be monitored for worsening

of depression symptoms and suicidal thoughts or behaviors.

5. 5. If a black box warning indicates that a resident should be monitored for suicidal thoughts or suicidal

behaviors, staff should monitor the resident for suicidal thoughts and suicidal behaviors.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview, LPN #17 stated the following: 1. R #16 was taking an anti-depressant for depression. 2. R #16 had a black box warning for escitalopram and trazadone orders that indicated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. R #16 was not monitored for suicidal thoughts or suicidal behaviors. 4. R #16 was not monitored for depression symptoms. 5. R #16 did not have any non-pharmacological interventions in place for his diagnosis of depression. 6. R #16 was being monitored for inappropriate sexual behaviors toward female staff and female residents. F. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. R #16's order for escitalopram had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 2. R #16's care plan did not include any specific behaviors related to depression that staff should monitor for. 3. R #16's care plan did not include any non-pharmacological interventions for his diagnosis of depression. 4. R #16's care plan did not include for staff to monitor R #16 for worsening depression or emergence of suicidal thoughts or suicidal behaviors. 5. Staff should include what interventions are in place to treat depression on the care plan. 6. Staff should include what behaviors residents were being monitored for on the care plan.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

level. 8. On 08/24/25 at 430 PM staff documented 4 BS 70. 9. On 08/25/25 at 430 PM staff documented 4 BS 65. 10. On 08/25/25 at 830 PM staff documented 4 BS 57. 11. On 08/26/25 at 1130 AM staff documented 4 BS 62. Q. Record review of Diabetic Management Policy dated 03/19/24 revealed the following: 1. ACUTE COMPLICATION MANAGEMENT: HYPOGLYCEMIA - Low Blood Sugar Levels a. If the BG (blood glucose/BS) level is below 70 mg/dl or other physician directed low parameter, and the resident can swallow, or the resident is tube fed: Give fast acting source of sugar and notify MD. b. Reassess the BG level in 15 minutes and document the results of the BG on the MAR. c. If the BG level remains below 70 mg/dl or other physician directed low parameter give: Additional source of sugar (e.g., another 4 ounces of orange juice or administer glucose gel. d. Recheck blood glucose in 15 minutes and document the results. e. Notify the physician of the episode. R. Record review of R #9's progress notes for August 2025 revealed

the following: 1. On 08/21/25 staff did not document R #9's BS level or the reason why insulin glargine was held. 2. On 08/25/25 for insulin glargine, staff documented blood glucose low. Staff did not consult the provider regarding holding the medication since the medication does not have hold parameters. 3. On 08/23/25, 08/24/25, 08/25/25 and 08/26/25 staff did not document that they gave juice, glucagon, rechecked the BS level or notified the provider of R #9's BS levels of 80 or less. S. On 10/17/25 at 11:00 AM, during an interview, the DON confirmed the following: 1. Staff did not contact the provider to notify them of R #1's and R #2's BP medications being held. 2. R #1's amlodipine and lisinopril orders did not have parameters indicating when the medications should be held. 3. R #2's amlodipine was held outside of set parameters. 4. R #9's insulin glargine was held, and the order did not have parameters indicating when to hold the medication. 5. Staff did not follow R #9's Humulin insulin order or the facility policy regarding low blood sugars. 6. Her expectation is that if staff have concerns regarding administering medications, they contact the provider, document the conversation held with provider and enter a new order as needed depending on what the provider's decision is regarding the medication.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to meet quality of care standards for 1 (R #9) of 3 (R #1, R #2, and R #9) residents reviewed for diabetes (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels) when staff did not obtain finger stick blood glucose levels for R #9 upon return to the facility. This deficient practice could likely result in complications related to diabetes.

The findings are: A. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE REDACTED]. 2. R #9 had a diagnosis of type 2 diabetes mellitus with hyperglycemia (DM2; chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels). B. Record review of R #9's nursing progress notes revealed the following: 1. R #9 was sent to the hospital on [DATE REDACTED] due to a fall at the facility. 2. R #9 was admitted to the hospital from [DATE REDACTED] through 08/31/25. C. Record review of R #9's convalescent care orders (CCO; discharge orders from the hospital for residents entering long-term care facilities), dated 08/31/25, revealed the following: 1. Treatment Orders: For patients with diabetes and accuchecks (routine blood glucose checks ordered for patients) a. Accuchecks

before meals and at bedtime (AC and HS; blood glucose checks performed before meals and at bedtime to manage diabetes effectively.)? Was answered Yes. D. Record review of R #9's provider progress notes revealed the following: 1. R #9 was seen by the facility provider on 09/03/25. 2. Under diagnosis, assessment, plan provider documented the following: a. Diabetes mellitus type 2, continue blood sugar checks before meals and at bedtime. E. Record review of R #9's physician's orders revealed no order for accuchecks/blood sugar checks was entered as indicated on the CCO and providers progress note for 09/03/25. F. Record review of R #9's blood sugar summary (vital sign section where staff document blood glucose levels) revealed no blood glucose checks were completed by staff after 08/26/25. G. On 10/16/25 at 2:31 PM, during an interview with the provider, he confirmed he did want R #9 to be on blood glucose checks upon his readmission from the hospital. He was unaware that this order had not been implemented upon R #9's return from the hospital.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the following dates: 1. 07/09/25. 2. 07/20/25. E. Record review of R #16's administration record, dated August 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 08/05/25 2. 08/06/25 F. Record review of R #16's administration record, dated September 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 09/08/25 2. 09/14/25 G.

Record review of R #16's provider progress notes, multiple dates, revealed the following: 1. On 05/23/25,

the provider documented that R #16 had depression and was not followed by psychiatry. 2. On 07/01/25,

the provider documented that R #16 had a diagnosis of depression and was not followed by psychiatry. 3.

On 08/23/25, the provider documented that R #16 had a diagnosis of depression and was not followed by psychiatry. H. Record review of R #16's Psychiatric Evaluation (a comprehensive assessment of an individual's mental health status conducted by a qualified mental health professional, such as a psychiatrist, psychologist, or social worker), multiple dates, revealed R #16 was seen on: 1. 03/14/25, the psychiatric provider recommended R #16 continue therapy services (resident was not receiving therapy services at that time, see finding I and M). 2. 10/06/25, after an episode of self-harm. I. Record review of R #16's entire medical record, no date, revealed R #16 was not seen for therapy services at the facility. J. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following: 1. R #16 was taking an anti-depressant for a diagnosis of depression. 2. R #16 did not have any non-pharmacological interventions in place for his diagnosis of depression. 3. She was unsure if R #16 was receiving behavioral health services. 4. R #16 frequently exhibited sexual behaviors toward female staff and female residents. 5. Staff were monitoring R #16 for his sexual behaviors toward female staff and female residents. 6. R #16's order to monitor compulsive behaviors was related to sexual behaviors. 7. She was the nurse working when R #16 had an episode of self-harm on 10/06/25. 8. R #16 had never stated suicidal thoughts or showed suicidal behaviors prior to 10/06/25. K. On 10/10/25 at 10:02 AM, during an interview, the SSD stated the following: 1. R #16 had a referral for [Name of psychiatric company] on 12/18/24. 2. R #16 was not seen by the psychiatric provider until 03/14/25. 3. She stated that when a referral is placed for a psychiatric provider, the nurses were expected to verbally notify her, then she sends the referral to the psychiatric provider. 4. R #16 had another referral, dated 07/20/25, for a psychiatric consult due to increased sexual behaviors. 5. R #16 was not seen by the psychiatric provider until 10/06/25. 6. She stated she did not have a method to track when

she was verbally notified about psychiatric referrals. L. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. Staff were expected to verbally notify the SSD when a psychiatric referral was ordered. 2. The SSD was expected to send the referral to the psychiatric provider. 3. There was no tracking method to ensure the SSD was notified and the referral was sent to the psychiatric provider. 4. Her expectation was for nursing staff to notify the psychiatric provider if a resident is having increased behaviors. 5. She was unable to determine when the SSD was notified about R #16's referrals on 12/18/24 or 07/20/25. 6. R #16 was seen by the psychiatric provider on 03/14/25 and after his episode of self-harm

on 10/06/25. M. On 10/10/25 at 12:20 PM, during an interview, the Medical Records Director confirmed R #16 was not being seen for counseling. N. On 10/10/15 at 12:55 PM, during an interview, the psychiatric nurse practitioner (PNP) confirmed the following: 1. He usually received referrals from the SSD via email. 2.

He was unsure when he was notified about R #16's first referral on 12/18/24. 3. He saw R #16 on 03/14/25.

1. 4. He was not notified that a new referral for R #16 was placed on 07/20/25. 5. He was not notified that R

#16 had sexual behaviors. 6. If he had been notified about R #16 having sexual behaviors, he would have followed up with him. 7. He saw R #16 after an episode of self-harm on 10/06/25. 8. He confirmed he did not see R #16 between the 03/14/25 and 10/06/25 visits.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to ensure the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication).

A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE REDACTED]. 2. R #16 had the following diagnoses: a. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances). b. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in

the morning, despite having adequate opportunity to sleep). c. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25.

1. 3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 4. An order dated

11/22/24 for trazadone (antidepressant medication that is also used to treat anxiety and insomnia) 25 mg, once a day for sleep aide. 5. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia. C.

Record review of R #16's pharmacist recommendation, dated 07/28/25, revealed the following: 1. R #16 had been taking escitalopram 20 mg once a day since 10/18/24. 2. The pharmacist recommended R #16 be evaluated to decrease the dose of escitalopram. 3. The provider documented resident with good response, maintain current dose. 4. The provider documented disagree with the pharmacist recommendation. 5. The provider did not document a clinical rationale for why R #16 should not have a dose reduction. D. Record

review of R #16's entire medical record, no date, revealed the provider did not document a clinical rationale for why a GDR should not be conducted for R #16 for escitalopram 20 mg. E. On 10/09/25 at 2:11 PM,

during an interview, the DON confirmed the following: 1. R #16 was taking the same dose of escitalopram and oxcarbazepine since he arrived on 10/17/24. 2. The pharmacist recommended a GDR for escitalopram

on 07/28/25 and the provider declined the GDR. 3. R #16's provider did not document a clinical rationale for why a GDR should not be conducted for escitalopram. F. On 10/14/25 at 12:29 PM, during an interview, the Medical Director confirmed the following: 1. A GDR for antidepressant medications should be attempted if a resident was not showing signs of depression. 2. Providers were expected to document a clinical rationale for why a GDR should not be attempted.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calibre Post Acute, LLC

2029 Sagecrest Ave Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Based on record review and interview, the facility failed to ensure nursing staff completed mandatory behavioral health training (a form of instruction that provides knowledge and skills to identify, understand, and respond to mental health and substance use challenges, including the promotion of well-being) for 1 (LPN #26) of 4 (LPN #17, LPN #18, LPN #25, and LPN #26) staff sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of staff training records revealed LPN #26 did not complete the mandatory behavioral health training. B. On 10/14/25 at 12:29 PM, during an interview,

the Administrator stated the following: 1. He was unable to find LPN #26's behavioral health training. 2. If LPN #26 did not complete the behavioral health training, he would ensure she completed it that day. 3. All staff were required to complete behavioral health training.

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Facility ID:

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