Federal inspection record · CMS data as of October 1, 2026
Fort Bayard Medical Center
41 Fort Bayard Road, Santa Clara, NM · (575) 537-3302
- Certified beds
- 200
- Residents per day
- 135
- Ownership
- Government
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 20, 2009
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in New Mexico.
-
Staffing
★★★★★+1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among New Mexico homes
Fort Bayard Medical Center carries 197.25 inspection points. That is fewer than 24% of New Mexico's 67 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in New Mexico: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–59 pts
- 4★ 59–97 pts
- 3★ 97–154 pts
- 2★ 154–212.75 pts
- 1★ over 212.75 pts
Bars show every rated home in New Mexico by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
63 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
H
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Resident Assessment and Care Planning16E
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Ensure each resident receives an accurate assessment.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- D
Plan the resident's discharge to meet the resident's goals and needs.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Rights11E
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care10E
- D
Provide safe, appropriate pain management for a resident who requires such services.
- E
Assist a resident in gaining access to vision and hearing services.
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide or obtain dental services for each resident.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- D
Provide enough food/fluids to maintain a resident's health.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Freedom from Abuse, Neglect, and Exploitation9E
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- E
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Infection Control6F
- E
Provide and implement an infection prevention and control program.
- E
Implement a program that monitors antibiotic use.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- F
Provide and implement an infection prevention and control program.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Pharmacy Service3E
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Nutrition and Dietary3F
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nursing and Physician Services2F
- F
Post nurse staffing information every day.
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Administration1F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspection history
2025-11-17
27 health deficiencies · 33 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2024-08-09
18 health deficiencies · 4 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2023-06-01
18 health deficiencies · 7 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 46 min of nursing staff time a day, 1 h 3 min of it from a registered nurse.
This home
5 h 46 min
New Mexico average
3 h 35 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 38% of nursing staff and 11% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$83,501 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-06-11 | Fine | $83,501 |
| 2024-06-11 | Payment Denial · 13 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts better | 1.2 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts worse | 3.2 | 2.6 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine10.4 pts worse | 85.7% | 96.1% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine6.5 pts worse | 89.3% | 95.8% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.6 pts better | 1.8% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.1 pts worse | 3.3% | 2.2% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.6 pts better | 2.9% | 3.5% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.4 pts worse | 22.2% | 14.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication10.9 pts worse | 25.4% | 14.5% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened8.2 pts worse | 18.5% | 10.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased11.8 pts worse | 22.1% | 10.3% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder2.9 pts worse | 3.7% | 0.8% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection9.9 pts worse | 10.9% | 1.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.8 pts worse | 20.0% | 19.2% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.7 pts worse | 9.9% | 5.2% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine36.8 pts worse | 49.3% | 86.1% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.5 pts better | 8.2% | 15.7% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine17.9 pts worse | 66.7% | 84.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission8.8 pts better | 13.3% | 22.1% | 23.4% |
·
Who owns and runs it
6 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bays, Sherri | Corporate Director · Individual | 0% | 1 facilities |
| Bays, Sherri | Corporate Officer · Individual | 0% | 1 facilities |
| Bays, Sherri | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Hamilton, Jason | Corporate Director · Individual | 0% | 1 facilities |
| Hamilton, Jason | Corporate Officer · Individual | 0% | 1 facilities |
| Hamilton, Jason | Operational/Managerial Control · Individual | 0% | 1 facilities |
·
Fire safety
44 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke15F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Provide properly protected cooking facilities.
- F
Provide properly protected cooking facilities.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- F
Provide properly protected cooking facilities.
- F
Inspect, test, and maintain automatic sprinkler systems.
Emergency Preparedness9F
- F
Establish procedures for tracking staff and patients during an emergency.
- F
Establish policies and procedures including evacuation.
- F
Provide emergency officials' contact information.
- F
Provide a means of sharing information on occupancy/needs.
- F
Conduct testing and exercise requirements.
- F
Address patient/client population and determine types of services needed.
- F
Establish roles under a Waiver declared by secretary.
- F
Provide a means of sharing information on occupancy/needs.
- F
Address patient/client population and determine types of services needed.
Miscellaneous7F
- F
Have simulated fire drills held at unexpected times.
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E
Have restrictions on the use of highly flammable decorations.
- D
Have restrictions on the use of portable space heaters.
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems7F
- F
Meet requirements for the installation and maintenance of electrical systems.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- E
Ensure proper usage of power strips and extension cords.
- E
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Egress5F
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- F
Have properly located and lighted "Exit" signs.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Construction1F
- F
Meet other general requirements.
·
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