33 health deficiencies
Top issue: Resident Assessment and Care Planning (11 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mescalero, NM
2-star overall rating with 2-star inspections with $32,110 in total fines with 33 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
454 Lipan Avenue, Mescalero, NM
(575) 464-4802
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Beds
40
Certified beds
Average residents
1
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-12-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
12,638
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Performance 21.64% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.26
Performance 7.16% · Measure score 2.26 · Achievement 2.26 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.34% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 19.05% · Lower 95% interval 7.85% |
| Discharge to community | 52.47% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 47.62% · Lower 95% interval 38.87% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 70.45% |
8.2%
62.2 pts better
|
Numerator 31 · Denominator 44 |
| Staff flu vaccination coverage | 84.09% |
42%
42.1 pts better
|
Numerator 37 · Denominator 44 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
97.4%
5.7 pts worse
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.5%
3.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
1.8%
7.7 pts worse
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
14.1%
5.8 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
Survey summary
Top issue: Resident Assessment and Care Planning (11 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nursing and Physician Services (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-30
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-06
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-06
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-06
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-31
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-31
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-08-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-31
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-31
Inspection history
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2026-01-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-15
Health
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.
Corrected 2025-07-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-18
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-18
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-18
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-18
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-18
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-18
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-18
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-07-18
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-07-18
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-18
Health
Provide or obtain dental services for each resident.
Corrected 2025-07-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-18
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-07-18
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-07-18
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-07-18
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-07-18
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-07-18
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-18
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-07-18
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-18
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-07-18
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-07-18
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-18
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-07-18
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-07-18
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-17
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-08-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-05
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-08-05
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-05
Health
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.
Corrected 2024-08-05
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-08-05
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-05
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-05
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-08-05
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-05
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-05
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-08-31
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-31
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-31
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-08-31
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-08-31
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-08-31
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-31
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-31
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-08-31
Health
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.
Corrected 2023-08-31
Health
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.
Corrected 2023-08-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-31
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-08-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-31
Penalties and ownership
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $13,762
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
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