Fort Bayard Medical Center
41 Fort Bayard Road, Santa Clara, NM 88026
Fort Bayard Medical Center, a 200-bed government - state nursing facility in Santa Clara, NM, holds a 3-star CMS overall rating - right around the 3.0-star national average, with nurse staffing above the national norm. 2 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 5755378604
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- 3 / 5
- Average · CMS overall · nat'l 3.0
- 6.48
- Well above average · nurse hrs/day · nat'l 3.89
- 47
- Inspection findings · 2 serious
- $84K
- Federal penalties (1)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 325120
- Ownership
- Government - State
- Provider Type
- Medicare and Medicaid
- Beds
- 200
- Residents
- 114
- In Hospital
- No
- County
- Grant
- Last Inspection
- Aug 9, 2024
Staffing Data
How the 6.48 total nursing hours per resident-day are staffed:
- RN Hours
- 1.23 (nat'l avg: 0.68)
- LPN Hours
- 0.56
- CNA Hours
- 4.70
- Total Nursing Hours
- 6.48 (nat'l avg: 3.89)
- PT Hours
- 0.00
- Nursing Turnover
- 40.3%
- RN Turnover
- 16.1%
What the CMS Record Reveals About Fort Bayard Medical Center
Fort Bayard Medical Center operates 200 certified beds in Santa Clara, NM with approximately 114 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars (health inspection 2★ · staffing 5★ · quality 2★).
The inspection file contains 47 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS enforcement records show 1 penalty totaling $84K levied against this facility. Per resident day, this facility reports 6.48 total nursing hours (national average 3.89) and 1.23 RN hours.
Classified as "Government - State" ownership and operating as a "Medicare and Medicaid" provider, Fort Bayard Medical Center falls into a category where comparative context matters. Reported nursing turnover at this facility is 40.3%, within a range generally associated with stable care teams.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (47 most recent)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 24, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 24, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 24, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Aug 24, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 1, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 25, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 25, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Oct 25, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 25, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 25, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 25, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 25, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 25, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 25, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Oct 25, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Oct 25, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Oct 25, 2024
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 26, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 26, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 26, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 26, 2024
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 26, 2024
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 8, 2023
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category: Infection Control Deficiencies
Corrected: Sep 8, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 8, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 8, 2023
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 8, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 8, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 8, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 8, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 8, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 8, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Sep 8, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Sep 8, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Sep 8, 2023
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Apr 30, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 30, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 30, 2022
Provide or obtain dental services for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 30, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 30, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 30, 2022
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 30, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 30, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Apr 30, 2022
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Apr 30, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 30, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.9% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 6.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 9.7% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.6% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 17.0% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 10.7% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 20.4% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.4% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.7% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 97.9% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 22.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.1% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 22.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 66.3% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 65.2% | No |
Penalty History 1 penalties totaling $84K
| Date | Type | Amount |
|---|---|---|
| Jun 11, 2024 | Fine | $84K |
| Jun 11, 2024 | Payment Denial | - |
| Jun 1, 2023 | Payment Denial | - |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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