Silver City Care Center
Silver City Care Center in Silver City, NM — inspection on January 28, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the interview, the Administrator reported that she did not believe that there was any effect to R #16 because she was already deceased when it happened.
I.
Record review of CMA #1's written statement dated [DATE], revealed NA #1 was asked to take R #16's vitals and R #16 had already passed away and checking the vital signs was as a friendly joke.
J.
Record review of SSD's written statement dated [DATE], revealed NA #1 told her that she was asked to get R #16's vitals, and R #16 was already dead. SSD said that NA #1 stated she was freaked out really bad by what had happened.
K. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls.
L. On [DATE] at 4:13 PM, during an interview with R #16's son (Son #2), he said that R #16 would have been horrified that a staff member was sent into her room after she had passed away to check her vitals as a prank.
Son #2 said it was disgusting that they [staff] did that to his mother.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
additional retraining will be offered by the Administrator and DON along with New Mexico Market level
jeopardy to resident health or and treating co-workers with respect and with a monitoring plan in place to ensure this does not safety recur.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
ombudsman, before transfer or discharge, including appeal rights.
and the Ombudsman received a written notice of transfer as soon as practicable for 4 (R #8, R #9, R
deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged .
The findings are: R #8 A.
Record review of R #8's medical record revealed the following:
- On 12/07/24, the facility transferred R #8 to the hospital for a fall.
- On 12/08/24, the facility transferred R #8 to the hospital for evaluation of abdominal wound and
- The record did not contain any written transfer notices.
fever
R #9 B.
Record review of R #9's medical record revealed the following:
- On 12/09/24, R #9 was sent to the hospital for abnormal lab results.
- The record did not contain a written transfer notice.
R #11 C.
Record review of R #11's medical record revealed the following:
- On 12/22/24, R #11 was sent to the hospital for fall.
- The record did not contain a written transfer notice.
R #13 D.
Record review of R #13's medical record revealed the following:
- On 09/14/24, R #13 was sent to the hospital for altered mental status.
- The record did not contain a written transfer notices.
E. On 01/08/25 at 2:55 PM, during an interview, the DON confirmed R #8, R #9, R #11, and R #13 did not have any transfer notices.
The DON said that transfer notices should be done at the time of transfer or as soon as practicable.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
resident?s bed in cases of transfer to a hospital or therapeutic leave.
received a written notice of the bed hold policy which indicated the duration the bed would be held for
hospitalization.
This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.
The findings are: R #8 A.
Record review of R #8's medical record revealed the following:
- On 12/07/24, the facility transferred R #8 to the hospital for a fall.
- On 12/08/24, the facility transferred R #8 to the hospital for evaluation of abdominal wound and
- R #8's record did not contain a written notices of the bed hold notice.
fever.
R #9 B.
Record review of R #9's medical record revealed the following:
- On 12/09/24, R #9 was sent to the hospital for abnormal lab results.
- R #9's record did not contain a written notice of the bed hold notice.
R #11 C.
Record review of R #11's medical record revealed the following:
- On 12/22/24, R #11 was sent to the hospital for fall.
- R #11's record did not contain a written notice of the bed hold notice.
R #13 D.
Record review of R #13's medical record revealed the following:
- On 09/14/24, R #13 was sent to the hospital for a change in mental status.
- R #13's record did not contain a written notice of the bed hold notice.
E. On 01/08/25 at 2:55 PM, during an interview, the DON confirmed that she did not see any bed holds for R #8, R #9, R #11, and R #13.
The DON did not remember when the bed hold should be provided to the resident.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
- R #1 had a diagnosis of need for assistance with personal care.
I. On 01/22/25 at 2:22 PM, during an interview, NA #3 said R #17 does not like having his teeth brushed and refuses sometimes.
J.
Record review of R #17's care plan dated 10/20/24, revealed the care plan did not contain any documentation of R #17 refusing assistance and any interventions on how staff will assist or encourage R #17 when he refuses having his teeth brushed.
K. On 01/22/25 at 3:11 PM, during an interview, the DON confirmed staff did not document that R #17 was not compliant with brushing his teeth on his care plan.
The DON said that resident's refusals should be documented and that interventions should be care planned.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
times a day.
The DON confirmed the documentation revealed R #17 was not getting his teeth brushed regularly in the mornings and the night shift was more consistent at documenting that his teeth are being brushed.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
held when her blood glucose levels are above 100 that the order was not being followed. DR #1
#1 said that he does not know why the orders were not being followed.
325091 01/28/2025
Silver City Care Center 3514 Fowler Avenue Silver City, NM 88061
facility.
The Senior Operation resource lead also will assume the role of the facility abuse coordinator
jeopardy to resident health or safety -A full investigative audit occurred within the facility from [DATE] through [DATE] to ensure no other current residents have been mistreated or have felt they were treated undignified.
Residents
and for the residents not able to answer, their families/POA's (Power of Attorney the authority to act for another person in specified or all legal or financial matters) /guardians were called and asked the same question. and if any further mistreatment or undignified treatment comes forward, the facility will remove any resident from the situation, and proper monitoring and interventions will be initiated immediately upon notification. No new allegations of abuse have been provided. -If any staff are identified in an allegation of abuse, neglect, undignified behavior or mistreatment, the staff member will be removed from the situation to ensure resident safety and dignity, and the staff member will immediately be placed on administrative leave pending the investigation completion. -On [DATE] the identified RN of concern was placed on administrative leave pending the investigation.
The RN's last scheduled day of work was [DATE].
During the interview, the Administrator reported that she did not believe that there was any effect to R #16 because she was already deceased when it happened.
The Administrator confirmed that there was not any education for RN #1 or other staff regarding respecting deceased residents.
F.
Record review of the facility's self report dated [DATE] identified Care concerns have been reported for this resident [R #16].
Investigation started.
325091
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 325091 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Silver City Care Center 3514 Fowler Ave Silver City, NM 88061
A. On [DATE] at 4:36 PM, during an interview, NA #1 stated she got to work on [DATE] at 6:00 am. NA #1 said that she noticed R #16's door was closed, and the door being closed was unusual. NA #1 said that at 6:30 AM, RN #1 asked her to take R #16's vital signs. NA #1 stated when she went into R #16's room, the room was cold. NA #1 said R #16 would usually respond to her right away when entering the room. NA #1 said R #16's dentures did not seem to be sitting right in her mouth. NA #1 further stated R #16 did not respond to her, she nudged R #16 and noticed at that time she was cold. NA #1 stated she realized R #16 had passed, so she left the room to let staff know and RN #1 was standing outside the room laughing. NA #1 stated RN #1 said it was a cruel rookie joke that he was playing and RN #1 told NA #1 not to say anything because he wanted to play the joke on another staff. NA #1 said that she was so distraught that emergency medical services had to be called to check her out because she was having a panic attack.
B.
Record review of a written statement dated [DATE], from CMA #1 revealed there was another staff member that was going to be asked to take vital signs on the deceased resident as a friendly joke but that staff member did not report to work. CMA #1 wrote NA #1 was the one sent into the room [to be pranked].
325091
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 325091 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Silver City Care Center 3514 Fowler Ave Silver City, NM 88061
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.