Health Inspection - MESCALERO CARE CENTER

F-F0500, interview for activity preferences. How important is it to you to participate in religious services or practices? staff documented 1, very important Level of Harm - Minimal harm or potential for actual harm I. Record review of R #9's care plan, initiated on 09/23/24, revealed staff did not document the following:

Residents Affected - Few 1. R #9's religion to include information on her distinct beliefs and practices.

2. Religious services and practices are very important to R #9.

J. On 05/19/25 at 2:49 PM, during an interview, the MDS Coordinator confirmed the following:

1. Per documentation of the Activities Review and MDS Activities section R #9 did inform facility staff regarding the importance of her religion and religious practices.

2. R #9's care plan did not include her religion and religious preference or what specific activities R #9 could and could not participate in.

3. R #9's religious information should be included in her comprehensive care plan.

52223

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755

Residents Affected - Some Recite from 05/22/24

Based on record review and interview, the facility failed to ensure care plan revisions occurred for 4 (R #9, R #11, R #118, and R #130) of 6 (R #9, R #11, R #118, R #119, R #121, and R #130) residents when the staff failed to revise the care plan with the most current resident information. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:

R #9

A. Record review of R #9's Admission Record (no date) revealed R #9 was admitted to the facility on [DATE REDACTED].

B. Record review of R #9's CNA shower review forms dated 02/03/25 through 05/15/25 revealed the following:

1. R #9 was offered showers twenty-three times.

2. R #9 refused her showers eleven of the twenty-three times showers were offered to her.

C. Record review of R #9's care plan dated 09/17/24 revealed the following:

1. R #9 requires partial/limited assistance with bathing/showering.

2. R #9's care plan was not revised to include residents refusal of showers and what actions staff could take to encourage her to shower.

D. On 05/19/25 at 4:19 PM, during an interview, the MDS Coordinator confirmed that R #9's care plan was not revised to include her refusal of care (refusing to shower) and actions that staff could take to assist her to agree to shower.

R #11

E. Record review of R #11's admission documents, no date, revealed the following:

1. R #11 was admitted to the facility on [DATE REDACTED].

2. R #11 had the following diagnoses:

a. Lack of coordination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0657 b. Muscle weakness.

Level of Harm - Minimal harm or c. History of falling. potential for actual harm F. Record review of R #16's progress note dated 04/16/25 revealed R #11 fell and was sent to the hospital. Residents Affected - Some G. Record review of the facility's follow-up report, dated 04/18/24, revealed the facility implemented increased monitoring and redirection as interventions to prevent R #11 from falling again.

H. Record review of R #11 care plan, revised 04/02/25, revealed staff did not revise R #11's care plan after

she fell on [DATE REDACTED].

I. On 05/19/25 at 2:31 PM, during an interview, the DON confirmed the following:

1. R #11 fell on [DATE REDACTED].

2. Close monitoring and redirection are interventions that are in place to prevent R #11 from falling.

3. R #11's care plan was not revised to include these interventions.

4. R #11's care plan should have been revised to include these interventions.

R #118

J. Record review of R #118's admission documents, no date, revealed the following:

1. R #118 was admitted to the facility on [DATE REDACTED].

2. R #118 had the following diagnoses:

a. History of falling.

b. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities).

K. On 05/12/25 at 3:47 PM, during an interview with R #118's family member (FM) #1 the following was revealed:

1. R #118 fell approximately four weeks prior to the interview (FM #1 was unsure of the date).

2. R #118 tried to get out of bed on her own.

3. The facility placed a fall mat and R #118's bed in lowest position when she is in bed.

4. The provider ordered hydroxyzine to be added to R #118's medications to help with anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0657 L. Record review of R #118's physician's orders, multiple dates, revealed the following:

Level of Harm - Minimal harm or 1. An order dated 03/15/25, for a fall mat and bed to be in lowest position when R #118 is in bed. potential for actual harm 2. An order dated 04/03/25, for hydroxyzine 25 mg at bedtime for anxiety and restlessness. Residents Affected - Some M. Record review of R #118's care plan, revised 03/24/25, revealed the following:

1. R #118's care plan was not revised to include a fall mat next to her bed or the bed to be in lowest position when she is in bed.

2. R #118's care plan was not revised to include R #118's order for hydroxyzine for anxiety or restlessness.

N. On 05/14/25 at 10:27 AM, during an interview, the DON confirmed the following:

1. R #118's care plan was not revised to include a fall mat next to R #118's bed and the bed to be in lowest position when she was in bed.

2. She confirmed that resident care plans are expected to be revised with any interventions in place to prevent them from falling.

R #130

O. Record review of R #130's Admission Record (no date) revealed R #130 was admitted to the facility on [DATE REDACTED].

P. Record review of R #130's physician's orders revealed the following:

1. Alprazolam (generic for Xanax; medication primarily used to treat anxiety disorders and anxiety associated with depression) 0.25 mg, give 1 tablet by mouth three times daily for anxiety (mental health condition characterized by excessive fear, and worry that interfere with daily life) and restlessness (feelings of irritability, nervousness and mental distress). Start date 04/16/25.

2. Hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 25 mg, give one tablet by mouth two times daily related to anxiety. Start date: 04/19/25.

Q. Record review of R #130's care plan revised on 04/30/25 revealed the following:

1. R #130 uses anti-anxiety medications (Xanax) related to anxiety disorder.

2. R #130's care plan was not revised to include that R #130 also takes hydroxyzine for anxiety.

R. On 05/19/25 at 2:20 PM, during an interview, the MDS Coordinator confirmed that R #130's care plan was not revised to include that R #130 also takes hydroxyzine for anxiety.

49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755 potential for actual harm Based on observation, record review, and interviews, the facility failed to meet professional standards of Residents Affected - Some practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #1 and R #121) of 2 (R #1 and R #121) residents reviewed for unnecessary medication use and wound care when staff failed to:

1. Notify the physician about R #1's elevated blood pressure as indicated on physician's order.

2. Obtain wound care orders prior to performing wound care on R #121's right leg.

If the facility is not providing care per physician's orders and care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are:

R #1

A. Record review of R #1's admission record (no date) revealed the following:

1. R #1 was admitted to the facility on [DATE REDACTED].

2. R #1 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors).

B. Record review of R #1's physician orders revealed an order for Amlodipine (high blood pressure primarily used to treat high blood pressure and chest pain by relaxing blood vessels which lowers blood pressure and decreases the hears workload) tablet 10 mg, give 1 tablet by mouth in the morning for high blood pressure (HTN; hypertension medical term for high blood pressure) hold (do not give medication) and call doctor if systolic blood pressure (SBP, top number of blood pressure reading ) is less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) is less than 50 and/or pulse (heart rate, beats per minute) is less than 50. Administer (give medication) and call doctor if SBP is greater than 180, DBP is greater than 100 and/or Pulse is greater than 100.

C. Record review of R #1's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following:

1. On 04/01/25 staff documented bp 195/63 and administered amlodipine.

2. On 04/05/25 staff documented bp 181/64 and administered amlodipine.

3. On 04/08/25 staff documented pulse 47 and administered amlodipine.

4. On 04/08/25 staff documented pulse 43 and administered amlodipine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 5. On 04/09/25 staff documented bp 184/81 and administered amlodipine.

Level of Harm - Minimal harm or 6. On 04/12/25 staff documented bp 189/78 and administered amlodipine. potential for actual harm D. Record review of R #1's MAR dated May 2025, revealed staff documented the following: Residents Affected - Some 1. On 05/04/25 staff documented bp 190/82 and administered amlodipine.

2. On 05/05/25 staff documented bp 198/74 and administered amlodipine.

3. On 05/06/25 staff documented bp 189/73 and administered amlodipine.

4. On 05/07/25 staff documented bp 185/76 and administered amlodipine.

5. On 05/10/25 staff documented bp 185/79 and administered amlodipine.

6. On 05/11/25 staff documented bp 217/92 and administered amlodipine.

7. On 05/13/25 staff documented bp 185/79 and administered amlodipine.

8. On 05/14/25 staff documented bp 182/70 and administered amlodipine.

9. On 05/15/25 staff documented bp 215/74 and administered amlodipine.

E. Record review of R #1's progress notes for March and April 2025, revealed staff did not document that

they notified the physician of R #1's elevated blood pressure (SBP higher than 180) or low pulse (heart rate less than 50).

F. On 05/19/25 at 3:19 PM, during an interview, the DON confirmed the following:

1. R #1's blood pressure was elevated, and her pulse was low.

2. R #1's order indicates that staff are to call physician when blood pressure is greater than 180 and heart rate is less than 50.

3. Facility staff did not call the physician as indicated on the order and staff are expected to follow the physician's order.

R #121

G. Record review of R #121's admission record (no date) revealed the following:

1. R #121 was admitted to the facility on [DATE REDACTED].

2. R # 121 had a diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of unspecified toe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 H. On 05/12/25 at 2:18 PM, during an interview and observation of R #121, the following was revealed:

Level of Harm - Minimal harm or 1. R #121 stated she had cellulitis in both legs. potential for actual harm 2. Her right leg was worse than her left leg. Residents Affected - Some 3. She stated that the nurses were performing wound care on both of her legs.

4. She had bandages to both legs.

5. She stated she was on antibiotics for the cellulitis.

6. The provider ordered for her to see the wound care specialist, but she didn't know the date of the scheduled appointment.

I. Record review of R #121's physician orders, multiple dates, revealed the following:

1. An order dated 04/16/25, for dry dressing and kerlix (bandage roll that provides absorbency and aeration) wrap to left lower leg blister every day and as needed until healed.

2. R #121's medical record did not have orders for wound care for R #121's right leg.

J. Record review of R #121's TAR for May 2025 revealed the following:

1. dry dressing and kerlix wrap to left lower leg blister every day and as needed until healed.

2. Staff documented treatment was administered as ordered.

K. On 05/15/25 at 12:27 PM, during an interview with RN #17, the following was revealed:

1. R #121 has wounds on both of her legs.

2. R #121's right leg wounds were worse than her left.

3. She performed wound care on both of R #121's legs.

4. For wound care, she washed R #121's wounds with wound care solution or normal saline (a mixture of water and salt with a salt concentration of .9%). Then put a non-adhesive (non-stick) dressing over the wounds and wrapped with kerlix.

5. She confirmed that R #121 had wound care orders for her left leg.

6. She confirmed that R #121 did not have orders for wound care to her right leg.

7. She stated that R #121's wounds on both legs were healing.

8. She confirmed R #121 had an appointment scheduled with the wound care specialist on 05/19/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 L. On 05/19/25 at 2:24 PM, during an interview, the DON confirmed the following:

Level of Harm - Minimal harm or 1. R #121 had cellulitis in both legs. potential for actual harm 2. Staff were performing wound care on both of R #121's legs. Residents Affected - Some 3. R #121 did not have physician's orders for wound care for R #121's right leg.

4. Staff were expected to get orders for wound care for R #121's right leg prior to performing wound care on

the right leg.

49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52223 potential for actual harm Based on record review and interview the facility failed to provide an ongoing activity program to support Residents Affected - Some residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 1 (R #4) of 1 (R #4) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are:

A. Record review of R #4's Admission record no date revealed an admitted [DATE REDACTED].

B. Record review of R #4's Annual MDS assessment dated [DATE REDACTED] revealed R #4's personal preferences for activities.

C. Record review of R #4's care plan dated 09/30/24 revealed R #4's care plan did not include her personal preferences from the MDS Annual Assessment.

D. Record review of R #4's Activity Individual Participation Record dated March 2025 revealed staff did not document that activities occurred for the following personal preferences:

1. Spiritual/religious activities.

2. Music.

3. Books, newspapers, and magazines to read.

E. Record review of R #4's Activity Individual Participation Record dated April 2025 revealed staff did not document that activities occurred for the following personal preferences:

1. Spiritual/religious activities.

2. Music.

3. Books, newspapers, and magazines to read.

F. Record review of R #4's Activity Individual Participation Record dated May 2025 revealed staff did not document that activities occurred for the following personal preferences:

1. Spiritual/religious activities.

2. Music.

3. Books, newspapers, and magazines to read.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0679 G. On 05/14/25 at 9:12 AM, during an interview, R #4 stated she was not offered activities in her room. R #4 stated no one comes in and watches tv with me, no talking or conversing. R #4 stated she would like a Level of Harm - Minimal harm or prayer, or bible study regarding Catholic religion, and likes all music, games, arts/crafts, gardening, any potential for actual harm activity would be nice because she was not offered them by staff.

Residents Affected - Some H. On 05/14/25 at 9:26 AM, during an interview with the Activities Director, she confirmed the following:

1. R #4's Annual MDS assessment dated [DATE REDACTED] is accurate and reflects resident's personal preferences for activities.

2. The Activities Director (AD) confirmed that she doesn't document everything for R #4 in the chart but is offering R #4 activities (contradicting R #4's statement). The AD will start documenting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49313

Residents Affected - Few Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #118) of 3 (R #11, R #118, and R #119) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #118 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed. The findings are:

A. Record review of R #118's admission documents, no date, revealed the following:

1. R #118 was admitted to the facility on [DATE REDACTED].

2. R #118 had the following diagnoses:

a. History of falling.

b. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities).

B. On 05/12/25 at 3:47 PM during an interview with R #118's family member (FM) #1 the following was revealed:

1. R #118 fell approximately four weeks prior to the interview (FM #1 was unsure of the date).

2. R #118 tried to get out of bed on her own.

3. The facility placed a fall mat and R #118's bed in lowest position when she is in bed after the fall.

C. Record review of R #118's physician's order, dated 03/15/25, for a fall mat and bed to be in lowest position when R #118 is in bed.

D. On 05/12/25 at 2:15 PM during observation of R #118 in her room, revealed the following:

1. R #118 laid in her bed.

2. The bed was at the lowest position with the head elevated.

3. A fall mat was folded up next to R #118's bathroom.

4. A fall mat was not next to R #118's bed.

E. On 05/13/25 at 2:25 PM during observation of R #118 in her room, revealed the following:

1. R #118 laid in her bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0689 2. The bed was at the lowest position with the head elevated.

Level of Harm - Minimal harm or 3. A fall mat was folded up next to R #118's bathroom. potential for actual harm 4. A fall mat was not next to R #118's bed. Residents Affected - Few F. On 05/13/25 at 2:33 PM during an observation of R 118's room and interview with LPN #16, the following was confirmed:

1. She confirmed that R #118 was in bed and her fall mat was not next to the bed.

2. R #118's fall mat was supposed to be next to her bed when R #118 was in bed.

G. On 05/13/25 at 2:35 PM during an interview, the DON confirmed the following:

1. R #118 had a history of falls.

2. R #118 had an order to have a fall mat next to her bed when she was in bed.

3. Staff were expected to put R #118's fall mat next to her bed when she was in bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755 potential for actual harm Recite from 05/22/24 Residents Affected - Some Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 60 days for 4 (R #1, R #9, R #10, and R #118) of 5 (R #1, R #9, R #10, R #118, and R #130) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are:

R #1

A. Record review of R #1's Electronic Medical Record (EMR) revealed the following:

1. R #1 was admitted to the facility on [DATE REDACTED].

2. R #1 was seen by the Medical Director (clinician who oversees and guides the care provider to nursing home residents) on 12/29/24.

3. R #1 was seen by the Medical Director on 05/10/25.

B. On 05/19/25 at 3:13 PM, during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days.

R #9

C. Record review of R #9's EMR revealed the following:

1. R #9 was admitted to the facility on [DATE REDACTED].

2. R #9 was seen by the Medical Director on 09/24/24.

3. R #9 was seen by the Medical Director on 05/02/25.

D. On 05/19/25 at 3:44 PM during an interview, the DON confirmed that R #1 was not seen by the provider every 60 days.

R #10

E. Record review of R #10's EMR revealed the following:

1. R #10 was admitted to the facility on [DATE REDACTED].

2. R #10 was seen at the local medical clinic on 07/24/24.

3. R #10 was seen by the Medical Director on 04/03/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0712 F. On 05/19/25 at 3:52 PM during an interview, the DON confirmed that R #10 was not seen by the provider every 60 days. Level of Harm - Minimal harm or potential for actual harm R #118

Residents Affected - Some G. Record review of R #118's EMR revealed the following:

1. R #118 was admitted to the facility on [DATE REDACTED].

2. Last physician visit was on 07/12/24.

H. On 05/14/25 at 12:42 PM, during an interview, the DON stated the following:

1. The physician went to the facility weekly.

2. The physician saw all new residents during her weekly visits.

3. The physician saw all residents receiving skilled services weekly.

4. The physician saw any resident who had a specific need to be seen.

5. The physician saw all residents annually.

6. The DON confirmed that R #118 had not been seen by the physician since 07/12/24.

49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 52223 potential for actual harm Based on interview and record review, the facility failed to complete performance reviews at least every 12 Residents Affected - Some months for 1 (CNA #26) of 2 (CNA #26 and CNA #28), CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are:

A. Record review of CNA #26's employee files revealed the following:

1. CNA #26's hire date was 07/18/11.

2. CNA #26's last performance review was 02/20/24.

B. On 05/19/25 at 2:48 PM during an interview, the Human Resource Manager confirmed that the last performance evaluation for CNA #26 was 02/20/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755

Residents Affected - Some Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 4 (R #9, R #10, R #11 and R #118) of 7 (R #1, R #9, R #10, R #11, R #118, R #119, and R #130) residents reviewed for unnecessary medications. 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). The findings are:

R #9

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 the following psychiatric diagnoses:

a. Anxiety disorder (mental health condition characterized by excessive fear, worry, and anxiety that interfere with daily life).

B. Record review of R #9's physician's orders revealed an order for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) give 50 mg by mouth one time a day for anxiety. Start date: 09/16/24.

C. Record review of R #9's MAR, dated 05/01/25 through 05/19/25, revealed the following:

1. On 05/01/25, R #9 received sertraline 50 mg in the morning.

2. On 05/02/25, R #9 received sertraline 50 mg in the morning.

3. On 05/03/25, R #9 received sertraline 50 mg in the morning

4. On 05/04/25, R #9 received sertraline 50 mg in the morning.

5. On 05/05/25, R #9 received sertraline 50 mg in the morning.

6. On 05/06/25, R #9 received sertraline 50 mg in the morning.

7. On 05/07/25, R #9 received sertraline 50 mg in the morning.

8. On 05/08/25, R #9 received sertraline 50 mg in the morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 9. On 05/09/25, R #9 received sertraline 50 mg in the morning.

Level of Harm - Minimal harm or 10. On 05/10/25, R #9 received sertraline 50 mg in the morning. potential for actual harm 11. On 05/11/25, R #9 received sertraline 50 mg in the morning. Residents Affected - Some 12. On 05/12/25, R #9 received sertraline 50 mg in the morning.

13. On 05/13/25, R #9 received sertraline 50 mg in the morning.

14. On 05/14/25, R #9 received sertraline 50 mg in the morning.

15. On 05/15/25, R #9 received sertraline 50 mg in the morning.

16. On 05/16/25, R #9 received sertraline 50 mg in the morning.

17. On 05/17/25, R #9 received sertraline 50 mg in the morning.

18. On 05/18/25, R #9 received sertraline 50 mg in the morning.

19. On 05/19/25, R #9 received sertraline 50 mg in the morning.

D. Record review of R #9's Note to attending physician/prescriber (form that documents pharmacist recommendation regarding residents' medication(s) to the physician/prescriber dated 03/03/25 revealed the following:

1. R #9 has been taking the antidepressant sertraline 50 mg once daily for anxiety since 09/17/24. Please evaluate the current dose and consider a dose reduction (GDR).

2. The form had Resident with good response, maintain the current dose and Disagree marked.

3. The medical director (clinician who oversees and guides the care provider to nursing home residents) did not provide rationale with patient specific information as to why R #10 needed to remain on the medication.

4. The form was signed by the medical director and dated 03/23/25.

E. On 05/19/25 at 3:50 PM, during an interview, the DON confirmed the following:

1. The pharmacist recommendation for R #9 was not implemented by the medical director.

2. The medical director did not provide a rationale for not performing a GDR for R #9's sertraline.

R #10

F. Record review of R #10's admission record, no date, revealed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 1. R #10 was admitted to the facility on [DATE REDACTED].

Level of Harm - Minimal harm or 2. R #10 had the following psychiatric diagnoses: potential for actual harm a. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Residents Affected - Some b. Restlessness and agitation (feelings of irritability, nervousness and mental distress).

G. Record review of R #10's physician's orders, multiple dates, revealed the following:

1. Order dated 04/11/24 and discontinued 11/26/24, for sertraline tablet (antidepressant medication used to treat anxiety and depression disorders) 50 mg, give 1 tablet by mouth in the morning related to depression.

2. Order dated 11/27/24, for sertraline tablet 50 mg, give 1 tablet by mouth in the morning for depression as evidenced by sadness.

3. Order dated 04/08/24 and discontinued 11/26/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia (common sleep disorder that makes it hard to fall asleep or stay asleep).

4. Order dated 11/27/24, for trazodone tablet give 50 mg by mouth at bedtime for insomnia.

5. Order dated 06/09/24 and discontinued 11/26/24, for escitalopram tablet (antidepressant medication used to treat anxiety and depression disorders) 10 mg, give 2 tablets by mouth in the morning for depression.

6. Order dated 11/27/24, for escitalopram tablet 10 mg, give 2 tablets by mouth in the morning for depression as evidenced by social isolation.

7. Order dated 04/22/24 and discontinued 11/26/24, hydroxyzine tablet (prescription-only antihistamine [medication with sedating and calming effect] that is used to treat anxiety) 10 mg, give 1 tablet by mouth two times a day for anxiety related to restlessness and agitation.

8. Order dated 11/27/24, hydroxyzine tablet 10 mg, give 1 tablet by mouth two times a day for anxiety as evidenced by restlessness and agitation.

H. Record review of R #10's MAR, dated 05/01/25 through 05/19/25, revealed the following:

Sertraline

1. On 05/01/25, R #10 received sertraline 50 mg in the morning.

2. On 05/02/25, R #10 received sertraline 50 mg in the morning.

3. On 05/03/25, R #10 received sertraline 50 mg in the morning

4. On 05/04/25, R #10 received sertraline 50 mg in the morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 5. On 05/05/25, R #10 received sertraline 50 mg in the morning.

Level of Harm - Minimal harm or 6. On 05/06/25, R #10 received sertraline 50 mg in the morning. potential for actual harm 7. On 05/07/25, R #10 received sertraline 50 mg in the morning. Residents Affected - Some 8. On 05/08/25, R #10 received sertraline 50 mg in the morning.

9. On 05/09/25, R #10 received sertraline 50 mg in the morning.

10. On 05/10/25, R #10 received sertraline 50 mg in the morning.

11. On 05/11/25, R #10 received sertraline 50 mg in the morning.

12. On 05/12/25, R #10 received sertraline 50 mg in the morning.

13. On 05/13/25 R #10 received sertraline 50 mg in the morning.

14. On 05/14/25, R #10 received sertraline 50 mg in the morning.

15. On 05/15/25, R #10 received sertraline 50 mg in the morning.

16. On 05/16/25, R #10 received sertraline 50 mg in the morning.

17. On 05/17/25, R #10 received sertraline 50 mg in the morning.

18. On 05/18/25, R #10 received sertraline 50 mg in the morning.

19. On 05/19/25, R #10 received sertraline 50 mg in the morning.

Trazodone

20. On 05/01/25, R #10 received trazodone 50 mg in the evening.

21. On 05/02/25, R #10 received trazodone 50 mg in the evening.

22. On 05/03/25, R #10 received trazodone 50 mg in the evening.

23. On 05/04/25, R #10 received trazodone 50 mg in the evening.

24. On 05/04/25, R #10 received trazodone 50 mg in the evening.

25. On 05/06/25, R #10 received trazodone 50 mg in the evening.

26. On 05/07/25, R #10 received trazodone 50 mg in the evening.

27. On 05/08/25, R #10 received trazodone 50 mg in the evening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 28. On 05/09/25, R #10 received trazodone 50 mg in the evening.

Level of Harm - Minimal harm or 29. On 05/10/25, R #10 received trazodone 50 mg in the evening. potential for actual harm . 30. On 05/11/25, R #10 received trazodone 50 mg in the evening. Residents Affected - Some 31. On 05/12/25 R #10 received trazodone 50 mg in the evening.

32. On 05/13/25, R #10 received trazodone 50 mg in the evening.

33. On 05/14/25, R #10 received trazodone 50 mg in the evening.

34. On 05/15/25, R #10 received trazodone 50 mg in the evening.

35. On 05/16/25, R #10 received trazodone 50 mg in the evening.

36. On 05/17/25, R #10 received trazodone 50 mg in the evening.

37. On 05/18/25, R #10 received trazodone 50 mg in the evening.

Escitalopram

38. On 05/01/25, R #10 received escitalopram 20 mg in the morning.

39. On 05/02/25, R #10 received escitalopram 20 mg in the morning.

40. On 05/03/25, R #10 received escitalopram 20 mg in the morning.

41. On 05/04/25, R #10 received escitalopram 20 mg in the morning.

42. On 05/05/25, R #10 received escitalopram 20 mg in the morning.

43. On 05/06/25, R #10 received escitalopram 20 mg in the morning.

44. On 05/07/25, R #10 received escitalopram 20 mg in the morning.

45. On 05/08/25, R #10 received escitalopram 20 mg in the morning.

46. On 05/09/25, R #10 received escitalopram 20 mg in the morning.

47. On 05/10/25, R #10 received escitalopram 20 mg in the morning.

48. On 05/11/25, R #10 received escitalopram 20 mg in the morning.

49. On 05/12/25, R #10 received escitalopram 20 mg in the morning.

50. On 05/13/25 R #10 received escitalopram 20 mg in the morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 51. On 05/14/25, R #10 received escitalopram 20 mg in the morning.

Level of Harm - Minimal harm or 52. On 05/15/25, R #10 received escitalopram 20 mg in the morning. potential for actual harm 53. On 05/16/25, R #10 received escitalopram 20 mg in the morning. Residents Affected - Some 54. On 05/17/25, R #10 received escitalopram 20 mg in the morning.

55. On 05/18/25, R #10 received escitalopram 20 mg in the morning.

56. On 05/19/25, R #10 received escitalopram 20 mg in the morning.

Hydroxyzine

57. On 05/01/25, R #10 received hydroxyzine 10 mg twice daily.

58. On 05/02/25, R #10 received hydroxyzine 10 mg twice daily.

59. On 05/03/25, R #10 received hydroxyzine 10 mg twice daily.

60. On 05/04/25, R #10 received hydroxyzine 10 mg twice daily.

61. On 05/05/25, R #10 received hydroxyzine 10 mg twice daily.

62. On 05/06/25, R #10 received hydroxyzine 10 mg twice daily.

63. On 05/07/25, R #10 received hydroxyzine 10 mg twice daily.

64. On 05/08/25, R #10 received hydroxyzine 10 mg twice daily.

65. On 05/09/25, R #10 received hydroxyzine 10 mg twice daily.

66. On 05/10/25, R #10 received hydroxyzine 10 mg twice daily.

67. On 05/11/25, R #10 received hydroxyzine 10 mg twice daily.

68. On 05/12/25, R #10 received hydroxyzine 10 mg twice daily.

69. On 05/13/25, R #10 received hydroxyzine 10 mg twice daily.

70. On 05/14/25, R #10 received hydroxyzine 10 mg twice daily.

71. On 05/15/25, R #10 received hydroxyzine 10 mg twice daily.

72. On 05/16/25, R #10 received hydroxyzine 10 mg twice daily.

73. On 05/17/25, R #10 received hydroxyzine 10 mg twice daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 74. On 05/18/25, R #10 received hydroxyzine 10 mg twice daily.

Level of Harm - Minimal harm or I. Record review of R #10's Recommendation Summary for DON and medical director (pharmacist potential for actual harm recommendation to the DON and medical director regarding residents' medications) dated 02/03/25, revealed the following: Residents Affected - Some 1. R #10 has a history of chronic depression and has been receiving the current dose sertraline 50 mg every morning since 04/11/24, trazodone 50 mg at bedtime since 04/08/24, and escitalopram 20 mg every morning since 06/09/24

2. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested.

3. The form had Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the residents function and or cause psychiatric instability. (Please elaborate with patient specific information marked.

4. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the medications.

5. The form was signed by the medial director and dated 03/23/25.

J. Record review of R #10's Note to attending physician (form that documents pharmacist recommendation regarding residents' medication(s) to the physician/prescriber dated 04/01/25, revealed the following:

1. R #10 has been taking the anxiolytic (class of medications used to prevent or treat anxiety symptoms or disorders) hydroxyzine 10 mg twice daily for anxiety since 04/22/24. Please evaluate the current dose and consider a dose reduction.

2. The form had Resident with good response, maintain the current dose marked.

3. The medical director did not provide rationale with patient specific information as to why R #10 needed to remain on the same dose of hydroxyzine.

4. The form was signed by the medical director and dated 04/03/25.

K. On 05/19/25 at 3:57 PM, during an interview, the DON confirmed the following:

1. The pharmacist recommendation for R #10 was not implemented by the medical director.

2. The medical director did not provide a rationale for not performing GDR's for R #10's medications.

R #11

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 L. Record review of R #11's admission record, no date, revealed the following:

Level of Harm - Minimal harm or 1. R #11 was admitted to the facility on [DATE REDACTED]. potential for actual harm 2. R #11 had the following psychiatric diagnoses: Residents Affected - Some a. Major Depressive Disorder (MDD, mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life)

b. Panic disorder [Episodic Paroxysmal Anxiety] (mental and behavioral disorder, specifically an anxiety disorder characterized by recurring unexpected panic attacks).

c. Psychotic Disorder with Hallucinations due to known physiological condition (a condition when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)).

d. Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep).

M. Record review of R #11's physician's orders, multiple dates, revealed the following:

1. Order dated 04/29/24, and discontinued 11/26/24, for buspirone (medication that can treat anxiety) 5 mg tablet, one tablet twice a day for anxiety.

2. Order dated 11/26/24, for buspirone 5 mg tablet, one tablet twice a day for anxiety.

3. Order dated 09/29/23 and discontinued 11/26/24, for lorazepam 0.5 mg tablet, one tablet twice a day for anxiety.

4. Order dated 11/26/24, for lorazepam (medication that can treat anxiety) 0.5 mg tablet, one tablet twice a day for anxiety.

5. Order dated 07/07/23 and discontinued 10/01/23, for trazadone 50 mg, one tablet in the evening for insomnia.

6. Order dated 10/01/23 and discontinued 11/26/24, for trazadone 50 mg, one tablet in the evening for depression, MDD, insomnia.

7. Order dated 11/26/24, for trazadone 50 mg tablet, one tablet in the evening for depression, MDD, insomnia.

8. Order dated 08/03/23 and discontinued 11/26/24, for mirtazapine 7.5 mg, give 1/2 of 15 mg tablet in the evening for depression.

9. Order dated 11/26/24, for mirtazapine 7.5 mg, give 1/2 of 15 mg tablet in the evening for depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 10. Order dated 06/30/23, for Nuplazid 34 mg, give one capsule at bedtime for hallucinations related to Parkinson's disease, psychotic disorder with hallucinations due to known physiological condition. Level of Harm - Minimal harm or potential for actual harm N. Record review of R #11's MAR, dated May 2025, revealed the following:

Residents Affected - Some 1. R #11 received Lorazepam 0.5 mg twice a day as ordered.

2. R #11 received buspirone 5 mg twice a day as ordered.

3. R #11 received trazadone 50 mg in the evening as ordered.

4. R #11 received mirtazapine 7.5 mg in the evening as ordered.

5. R #11 received Nuplazid 34 mg in the evening as ordered.

O. Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications), dated 05/02/25, revealed the following:

1. R #11 had an order for buspirone 5 mg twice a day since 04/29/24, and a GDR was declined in February 2025.

2. R #11 had an order for lorazepam 0.5 mg twice a day since 09/29/23, and a GDR was declined in September 2024.

3. R #11 had an order for mirtazapine (antidepressant medication) 7.5 mg in the evening for depression since 08/03/23, and a GDR was declined in September 2024.

4. R #11 had an order for Nuplazid 34 mg at bedtime since 06/30/23, and a GDR was recommended in April 2025.

5. R #11 had an order for trazadone 50 mg at bedtime since 10/01/23, and a GDR was declined in October 2024.

P. Record review of R #11's pharmacist recommendation, dated 08/03/24, revealed the following:

1. R #11 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg

in the evening for depression since 08/03/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested:

2. The form had Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information) selected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 3. The form had agree selected with a provider signature and date of 09/15/24.

Level of Harm - Minimal harm or 4. R #11's physician did not provide rationale with patient specific information as to why resident needed to potential for actual harm remain on medication.

Residents Affected - Some Q. Record review of R #11's pharmacist recommendation, dated 09/03/24, revealed the following:

1. R #11 has been taking the anxiolytic lorazepam 0.5 mg twice daily since 09/28/23. Please evaluate the current dose and consider a dose reduction.

2. The form had agree selected with a signature and date of 09/09/24.

3. The form had a note dated 09/16/24, verbal order to continue med. Per order by [Doctor Name].

4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication.

R. Record review of R #11's pharmacist recommendation, dated 10/04/24, revealed the following:

1. R #11 has a history of chronic depression and has been receiving the current dose of trazadone 50 mg at bedtime for depression since 10/01/23. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested:

3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication.

4. The form had a note, dated 10/14/24, [Name of nurse practitioner] verbal continue of this dose.

S. Record review of R #11's pharmacist recommendation, dated 02/03/25, revealed the following:

1. R #11 has been taking the anxiolytic buspirone 5 mg since 04/29/24. Please evaluate the current dose and consider a dose reduction (GDR).

2. The form had Condition stable: Attempt dose reduction to discontinue this medication, Resident with good response, maintain the current dose, and Disagree marked.

3. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication.

4. The form had a comment dated 02/19/25, MD intended to keep resident on current dose, verified by [DON signature].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 T. Record review of R #11's pharmacist recommendation, dated 04/05/25, revealed the following:

Level of Harm - Minimal harm or 1. R #11 has been taking the antipsychotic Nuplazid 34 mg at bedtime for psychotic disorder with potential for actual harm hallucinations related to Parkinson's Disease since 06/30/23. Please evaluate the current dose and consider

a dose reduction. Residents Affected - Some 2. The form had Resident with good response, maintain the current dose.

3. The form had agree selected with a signature and date of 05/09/25.

4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication.

U. On 05/19/25 at 2:34 PM, during an interview, the DON confirmed the following:

1. R #11 has not had a GDR for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid.

2. The provider did not provide a rationale for why she did not perform a GDR for R #11 for buspirone, lorazepam, mirtazapine, trazadone, or Nuplazid.

R #118

V. Record review of R #118's physician's orders, multiple dates, revealed the following:

1. An order, dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression.

2. An order, dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression.

W. Record review of R #118's MAR, dated 05/01/25 to 05/12/25, revealed the following:

1. On 05/01/25, R #118 received mirtazapine 7.5 mg in the evening.

2. On 05/02/25, R #118 received mirtazapine 7.5 mg in the evening.

3. On 05/03/25, R #118 refused mirtazapine 7.5 mg in the evening.

4. On 05/04/25, R #118 refused mirtazapine 7.5 mg in the evening.

5. On 05/05/25, R #118 received mirtazapine 7.5 mg in the evening.

6. On 05/06/25, R #118 received mirtazapine 7.5 mg in the evening.

7. On 05/07/25, R #118 received mirtazapine 7.5 mg in the evening.

8. On 05/08/25, R #118 received mirtazapine 7.5 mg in the evening.

9. On 05/09/25, R #118 received mirtazapine 7.5 mg in the evening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 10. On 05/10/25, R #118 received mirtazapine 7.5 mg in the evening.

Level of Harm - Minimal harm or 11. On 05/11/25, R #118 received mirtazapine 7.5 mg in the evening. potential for actual harm 12. On 05/12/25, R #118 refused mirtazapine 7.5 mg in the evening. Residents Affected - Some X. Record review R #118's pharmacist recommendation, dated 05/02/25, revealed the following:

1. R #118 has a history of chronic depression and has been receiving the current dose of mirtazapine 7.5 mg in the evening for depression since 07/15/24. Federal guidelines require assessment of medication therapy showing benefit to risk for continuing therapy and periodic dose reduction trials when medications may no longer be necessary. Please check the appropriate response and add additional information as requested:

3. The form a provider signature and date of 05/09/25.

4. R #11's physician did not provide rationale with patient specific information as to why resident needed to remain on medication.

Y. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following:

1. R #118 has not had a GDR for mirtazapine.

2. The provider did not provide a rationale for why she did not perform a GDR for R #118 for mirtazapine.

49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755 potential for actual harm Recite from 05/22/24 Residents Affected - Some Based on record review and interview the facility failed to ensure residents obtained dental services for 3 (R #9, R #10 and R #123) of 4 (R #9, R #10, R #121 and R #123) residents sampled for dental services, when staff failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are:

R #9

A. On 05/12/25 at 2:15 PM, during an interview, R #9 stated that she needed to have her dentures checked because they were loose.

B. Record review of R #9's Admission Record, no date, revealed an admitted [DATE REDACTED].

C. Record review of R #9's physician's order dated 09/16/24 revealed Dental consult as needed.

D. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #9 had not been seen by a dentist since her admission.

R #10

E. On 05/13/25 at 10:22 AM, during an interview, R #10's Power of Attorney (POA; legal document that appoints someone as a representative and allows them to act on one's behalf) stated that R #10 had a dental filling that fell out approximately 6 months ago. R #10's POA stated she asked for the facility to schedule an appointment, but she is unsure if she was seen by a dentist.

F. Record review of R #10's physician's order dated 05/20/24 revealed Dental consult as needed.

G. Record review of R #10's Weekly Oral/Dental Assessment, dated 11/29/24 revealed Upper gums red, irritated. Currently using medicated mouthwash for treatment. Resident broke her silver cap off a tooth yesterday 11/28/24. Transportation noted to make resident dentist appointment. Passed on in nursing report and nursing staff.

H. Record review of R #10's progress notes revealed Social Service Note dated 12/13/24 at 1:57 PM: POA reported that her filling fell out of her mouth, she did report it to nurse. POA request that she needs to be taken to a dentist.

I. On 05/15/25 at 1:58 PM, during an interview with Medical Records staff, she confirmed R #10 had not been seen by a dentist after 11/28/24.

R #123

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0791 J. Record review of R #123's face sheet, no date, revealed an admitted [DATE REDACTED].

Level of Harm - Minimal harm or K. On 05/13/25 at 2:23 PM, during an interview, R #123 stated he had toothache, and he has not been to the potential for actual harm dentist since his admission to the facility.

Residents Affected - Some L. Record review of R #123's treatment administration record dated 05/01/25 revealed dental consultation as needed.

M. On 05/14/25 11:19 AM during an interview, DON stated she did not know that R #123 had a tooth ache. DON confirmed that R #123 did not have a monthly dental assessment in his record, and R #123 has been at the facility since 05/06/25 and has not seen a dentist in this time.

52223

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 49313

Residents Affected - Many Based on an interviews the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows:

(A) A certified dietary manager; or

(B) A certified food service manager; or

(D) Had an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or

(E) Had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving.

This failure could potentially affect all 29 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 05/12/25). If the facility fails to employ qualified dietary staff, residents nutritional needs may not be met and they could likely suffer adverse outcomes. The findings are:

A. On 05/12/25 at 1:36 PM, during an interview, Dietary Staff #16 revealed that the facility did not have a dietary manager (DM).

B. On 05/12/25 at 1:38 PM, during an interview, [NAME] #16 revealed the following:

1. The facility did not have a DM.

2. They had not had a DM for approximately a month.

3. He was not sure if the facility had a dietitian.

C. On 05/15/25 at 12:17 PM, during an interview, the Administrator confirmed the following:

1. The dietitian works at the facility one day a week.

2. The facility had not had a DM since 04/18/25.

3. The facility hired a DM that was expected to start on 05/23/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49313

Residents Affected - Many Recite from [DATE REDACTED]

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 29 residents in the facility (residents were identified by resident matrix provided by the Administrator on [DATE REDACTED]) who eat food or drinks stored in

the nutrition refrigerator or freezer when staff failed to:

1. Maintain refrigerator temperatures in the nutrition refrigerators (refrigerator near the nursing station that contains drinks and snacks for residents).

2. Food stored in the nutrition refrigerator was not expired.

3. Food stored in the nutrition refrigerator or freezer had an expiration date.

4. Food that was supposed to be frozen was not thawed in the refrigerator.

If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are:

A. On [DATE REDACTED] at 11:53 AM, during an observation of the nourishment room refrigerator revealed there was no temperature log for the refrigerator or freezer.

B. On [DATE REDACTED] at 11:54 AM, during an interview, RN #16 stated that the kitchen staff take the temperatures in

the nourishment room refrigerator.

C. On [DATE REDACTED] at 12:05 PM, during an interview, Dietary Aide (DA) #16 stated she was unsure where the nourishment room temperature log was.

D. On [DATE REDACTED] at 12:21 PM, during an observation of the nutrition refrigerator and freezer revealed the following:

1. A sandwich was in the refrigerator with a date written on it of [DATE REDACTED].

2. A bag of shredded cheese in the refrigerator with an expiration date of [DATE REDACTED].

3. Several individually packaged peanut butter and jelly sandwiches in the refrigerator with no date and no expiration date. The wrappers stated thaw and serve (should be stored in the freezer until ready to serve).

E. On [DATE REDACTED] at 12:24 PM, during an interview, the DON confirmed the following:

1. The sandwich in the nutrition room refrigerator was expired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0812 2. The cheese in the nutrition room refrigerator was expired.

Level of Harm - Minimal harm or 3. The individually packaged peanut butter and jelly sandwiches did not have a date that they would expire. potential for actual harm 4. The individually packaged peanut butter and jelly sandwiches should have had a date that they expired Residents Affected - Many written on them and should have been stored in the freezer and not the refrigerator.

5. There was no refrigerator or freezer temperature log in the nutrition room.

6. She was unsure if anyone had been checking the temperature of the nutrition room refrigerator or freezer.

7. Kitchen staff were responsible for the following in the nourishment room:

a. Taking temperatures of the refrigerator and freezer.

b. Stocking refrigerator and freezer and other snacks in the room.

c. Removing expired items.

F. On [DATE REDACTED] at 12:38 PM, during an interview, DA #16 confirmed the kitchen staff had not been checking temperatures for the nutrition room refrigerator and freezer. She was unable to determine the last time the nutrition room refrigerator and freezer temperatures had been checked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755

Residents Affected - Some Recite from 05/22/24

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #9 and R #118) of 6 (R #1, R #9, R #10, R #118, R #130 and R #131) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are:

R #9

A. Record review of R #9's physician orders revealed the following:

1. An order dated 11/25/24 for acetaminophen (Tylenol; analgesic medication used to treat mild to moderate pain) tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for pain.

B. Record review of R #9's medication administration record (MAR; a form used to document medication administration), dated April 2025, revealed staff documented the following:

1. On 04/06/25 at 3:01 AM, staff documented acetaminophen was given for a pain level of 5 (pain scale 1-10, 10 highest).

2. On 04/08/25 at 1:30 PM, staff documented acetaminophen was given for a pain level of 4.

3. On 04/16/25 at 11:15 PM, staff documented acetaminophen was given for a pain level of 4.

4. On 04/30/25 at 4:25 AM, staff documented acetaminophen was given for a pain level of 6.

C. Record review of R #9's MAR dated May 2025, revealed staff documented the following:

1. On 05/09/25 at 4:54 AM, staff documented acetaminophen was given for a pain level of 6.

2. On 05/09/25 at 9:46 PM, staff documented acetaminophen was given for a pain level of 5.

3. On 05/13/25 at 2:45 AM, staff documented acetaminophen was given for a pain level of 3.

4. On 05/14/25 at 3:00 AM, staff documented acetaminophen was given for a pain level of 5.

5. On 05/16/25 at 5:46 AM, staff documented acetaminophen was given for a pain level of 5.

6. On 05/17/25 at 5:45 AM, staff documented acetaminophen was given for a pain level of 5.

7. On 05/17/25 at 5:08 PM, staff documented acetaminophen was given for a pain level of 5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0842 8. On 05/18/25 at 3:33 AM, staff documented acetaminophen was given for a pain level of 5.

Level of Harm - Minimal harm or D. Record review of R #9's progress notes dated April 2025 and May 2025 revealed the following: potential for actual harm 1. On 04/08/25 staff documented acetaminophen was given for throat pain. Residents Affected - Some 2. Staff did not document the reason acetaminophen was given for any other dates in April or May.

E. On 05/19/25 at 3:47 PM, during an interview with the DON, she confirmed the following:

1. Facility staff did not document the reason R #9 was given acetaminophen.

2. Facility staff did not document whether the acetaminophen was effective in treating R #9's complaints of pain.

3. She expects staff to document the location of the pain and whether the pain medication helped relieve the pain.

4. Documenting the pain location and effectiveness helps the facility staff and physician know if there needs to be additional treatment for complaints of pain or if medication changes are necessary.

R #118

F. Record review of R #118's admission record, no date, revealed the following:

1. R #118 was admitted to the facility on [DATE REDACTED].

2. R #118 did not have any mental health diagnoses.

G. Record review of R #118's physician's orders, multiple dates, revealed the following:

1. An order dated 07/15/24 and discontinued on 05/13/25, for Mirtazapine (antidepressant to treat major depressive disorder) 7.5 mg in the evening for appetite and depression.

2. An order dated 05/13/25, for Mirtazapine 7.5 mg in the evening for appetite and depression.

H. Record review of R #118's provider's progress note, dated 07/12/24, revealed R #118 had a diagnosis of major depressive disorder (MDD, mood disorder that causes a persistent feeling of sadness and loss of interest).

I. Record review of R #118's medical record, no date, revealed staff did not update R #118's medical diagnoses to include her diagnosis of MDD.

J. On 05/19/25 at 2:16 PM, during an interview, the DON confirmed the following:

1. R #118's did not have a diagnosis of depression in her list of diagnoses in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0842 2. R #118's provider progress note, dated 07/12/24, listed MDD as one of R #118's diagnoses.

Level of Harm - Minimal harm or 3. Staff did not update R #118's electronic medical record (EMR) with the diagnosis of MDD. potential for actual harm 4. Staff were expected to update resident EMR's with all new diagnoses Residents Affected - Some 49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 52223

Residents Affected - Some Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory Effective Communication training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff randomly 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 RN #24's Online Training Transcript, no date revealed effective communication training was not completed.

B. Record review of LPN #25's Online Training Transcript, no date revealed effective communication training was not completed.

C. Record review of CNA #26's Online Training Transcript, no date revealed effective communication training was not completed.

D. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that Effective Communication Training has not been completed for RN #24, LPN #25, and CNA #26.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0942 Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Level of Harm - Minimal harm or potential for actual harm 52223

Residents Affected - Some Based on record review and interview, the facility failed to provide resident rights training (training that helps staff promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination) for 4 staff (RN #24, LPN #25, CNA #26, and RN #27) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff sampled for training. This deficient practice could likely result in staff being unaware of residents rights resulting in negative psychosocial well-being for residents. The findings are:

A. Record review of staff training records revealed RN #24 did not complete training for resident rights.

B. Record review of staff training records revealed LPN #25 did not complete training for resident rights.

C. Record review of staff training records revealed CNA #26 did not complete training for resident rights.

D. Record review of staff training records revealed RN #27 did not complete training for resident rights.

E. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that RN #24, LPN #25, CNA #26, and RN #27 did not complete the training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 52223

Residents Affected - Few Based on record review and interview, the facility failed to provide abuse, neglect, and exploitation training to 1 staff (RN #24) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation. The findings are:

A. Record review of RN #24's training transcript, no date, revealed that abuse, neglect, and exploitation training was last completed 12/31/23.

B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that RN #24 did not complete the required training since 2023. The HRM confirmed that the training should be completed annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 52223

Residents Affected - Some Based on record review and interview, the facility failed to ensure that nursing staff have completed the mandatory QAPI (Quality Assurance/Performance Improvement) training for 3 (RN #24, LPN #25, CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor

the effectiveness of interventions. The findings are:

A. Record review of the employee training transcript, no date, revealed RN #24 did not complete QAPI training.

B. Record review of the employee training transcript, no date, revealed LPN #25 did not complete QAPI training.

C. Record review of the employee training transcript, no date, revealed CNA #26 did not complete QAPI training.

D. On 05/19/25 2:48 PM, during an interview, the Human Resource Manager confirmed that the QAPI training has not been completed for RN #24, LPN #25, and CNA #26.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 52223

Residents Affected - Some Based on record review and interview, the facility failed to provide infection control training (training that helps staff recognize various infection control prevention to help stop the spread of infections) for 2 (RN #24 and CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA #28) staff sampled for training. This deficient practice could likely result in inadequate infection control, and can lead to increased spread of resistant organisms, and risk of infections among residents and staff. The findings are:

A. Record review of staff training records revealed CNA #26 completed training for infection control on 11/11/22.

B. Record review of staff training records revealed RN #24 completed training for infection control on 12/31/23.

B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that CNA #26 and RN #24 did not complete the training for the year 2025. The HRM confirmed that the training should be completed annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 52223

Residents Affected - Some Based on record review and interview, the facility failed to ensure that each CNA received a minimum of 12 in-service hours a year based on hire date for 1 (CNA #26) of 2 (CNA #26, and CNA #28) CNAs sampled for training. If CNAs are not adequately trained, they are unable to provide the necessary care and services to residents. The findings are:

A. Record review of the facility's CNA training records revealed the following:

1. CNA #26 hire date was 07/18/11.

2. CNA #26 had 1 training in-service hour taken on 11/22/24.

B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager confirmed that CNA #26 did not have the minimum of 12 in-service hours a year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 76 325116 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325116 B. Wing 05/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mescalero Care Center 454 Lipan Avenue Mescalero, NM 88340

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

Level of Harm - Minimal harm or 52223 potential for actual harm Recite from 05/22/24 Residents Affected - Few Based on record review and interview, the facility failed to provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 1 (CNA #26) of 5 (RN #24, LPN #25, CNA #26, RN #27 and CNA # 28) staff sampled for training.

This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are:

A. Record review of the staff training records revealed CNA #26 did not complete training for behavioral health needs.

B. On 05/19/25 at 2:48 PM, during an interview, the Human Resource Manager (HRM) confirmed that CNA #26 did not complete the training for the year 2025. The HRM confirmed that the training should be completed annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 76 325116