Fort Bayard Medical Center: Data Analysis and Ratings
CMS Five Star Rating(4 out of 5):
41 FORT BAYARD ROAD SANTA CLARA, NM 88026
575-537-8604
Data date: May 01, 2023
The Most Important Data about Fort Bayard Medical Center
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at Fort Bayard Medical Center. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(4 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Worsening
Total Nursing Hours Spent Per Resident Per Day: 5.58
(The national average is 3.74 )
According to our analysis, Fort Bayard Medical Center is ranked #1 out of 7 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Fort Bayard Medical Center.
What is this page all about?
Below is everything shred of information that we can find about Fort Bayard Medical Center, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: May 01, 2023
Address: 41 FORT BAYARD ROAD
SANTA CLARA, NM 88026
Phone: 575-537-8604
Ranking: Fort Bayard Medical Center is ranked #1 out of 3 facilities within a 10 mile radius and #1 out of 7 facilities within a 25 mile radius.
Medicare Provider Number: 325120
Participating in Medicare Since: June 20, 2009
No. of Certified Beds: 200
No. of Residents: 99
Occupancy: 49.50 % (as of 05/21/2023 )
Amount fined in recent period: $1,625.00
Complaints filed: 0
Ratings History for Fort Bayard Medical Center
Review of Fort Bayard Medical Center Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 4: |
| Health Inspection Rating | 3: |
| Quality Rating | 3: |
| Staffing Rating | 5: |
Inspection Scores
| Cycle 1 Score (as of March 03, 2022) | 104 |
| Cycle 2 Score (as of January 27, 2021) | 16 |
| Cycle 3 Score (as of June 28, 2019) | 116 |
| Weighted All Cycles Score | 77 |
It has been 13 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Fort Bayard Medical Center including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | March 03, 2022 |
| Fire Safety Standard | February 03, 2021 |
| Fire Safety Standard | June 25, 2019 |
| Health Standard | March 03, 2022 |
| Health Standard | January 27, 2021 |
| Health Standard | June 28, 2019 |
| Infection Control | January 27, 2021 |
| Infection Control | December 01, 2020 |
| Infection Control | June 26, 2020 |
Owner and Operator Information for Fort Bayard Medical Center
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Business Entity Name:
STATE OF NEW MEXICO
Owners:
Managers and Directors:
- SHERRI BAYS (OPERATIONAL/MANAGERIAL CONTROL)
- SHERRI BAYS (DIRECTOR)
- SHERRI BAYS (OFFICER)
- SHERRI BAYS (MANAGING EMPLOYEE)
- JASON HAMILTON (OPERATIONAL/MANAGERIAL CONTROL)
- JASON HAMILTON (DIRECTOR)
- JASON HAMILTON (OFFICER)
- MARIA SUBLASKY (MANAGING EMPLOYEE)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of Fort Bayard Medical Center spends MORE time on average with its residents than the state average for total nursing homes spent per resident and MORE time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 1.10 | 0.64 / 0.65 |
| Case Mix | 0.34 | 0.33 / 0.39 |
| Adjusted | 1.25 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 0.43 | 0.66 / 0.88 |
| Case Mix | 0.67 | NA / NA |
| Adjusted | 0.48 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 4.05 | 2.18 / 2.21 |
| Case Mix | 1.94 | NA / NA |
| Adjusted | 4.26 | NA / NA |
| Total Licensed Staff | ||
| Hours | 1.53 | 1.29 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.07 | 0.08 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 5.58 | 3.47 / 3.74 |
| Case Mix | 2.95 | 2.92 / 3.16 |
| Adjusted | 5.98 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison | |
|---|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | Not Available | ||
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | Not Available | ||
| Number of hospitalizations per 1000 long-stay resident days (qm551) | 0.4% |
1.5% Better |
|
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | 0.4% |
1.6% Better |
|
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 17.0% |
16.2% Worse |
|
| Percentage of long-stay residents who lose too much weight (qm404) | 4.1% |
7.1% Better |
|
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | 48.9% |
43.2% Worse |
|
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 4.4% |
2.2% Worse |
|
| Percentage of long-stay residents with a urinary tract infection (qm407) | 3.1% |
1.5% Worse |
|
| Percentage of long-stay residents who have depressive symptoms (qm408) | 2.7% |
3.3% Better |
|
| Percentage of long-stay residents who were physically restrained (qm409) | 0.0% |
0.1% Better |
|
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 3.0% |
3.5% Better |
|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 96.4% |
96.9% Worse |
|
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 18.1% |
16.9% Worse |
|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 26.1% |
79.6% Worse |
|
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | Not Available | ||
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | 13.1% |
15.7% Better |
|
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 23.9% |
12.8% Worse |
|
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | 11.1% |
8.0% Worse |
|
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | 100.0% |
95.1% Better |
|
| Percentage of short-stay residents who made improvements in function (qm471) | Not Available | ||
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | Not Available | ||
Fort Bayard Medical Center Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $1,625.00, Complaints filed: 0
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Establish procedures for tracking staff and patients during an emergency. (Fire Safety) | 06-25-2019 / 07-28-2019 |
| Establish policies and procedures for volunteers. (Fire Safety) | 06-25-2019 / 07-28-2019 |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Health) | 06-28-2019 / 08-21-2019 |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (Health) | 06-28-2019 / 08-21-2019 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 06-28-2019 / 08-21-2019 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 06-28-2019 / 08-21-2019 |
| Ensure services provided by the nursing facility meet professional standards of quality. (Health) | 06-28-2019 / 08-21-2019 |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Health) | 06-28-2019 / 08-21-2019 |
| 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. (Health) | 06-28-2019 / 08-21-2019 |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. (Health) | 06-28-2019 / 08-21-2019 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Health) | 06-28-2019 / 08-21-2019 |
| 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. (Health) | 06-28-2019 / 08-21-2019 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 06-28-2019 / 08-21-2019 |
| Provide and implement an infection prevention and control program. (Health) | 06-28-2019 / 08-21-2019 |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (Health) | 06-28-2019 / 08-21-2019 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 01-27-2021 / 03-31-2021 |
| 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. (Health) | 01-27-2021 / 03-31-2021 |
| Inspect, test, and maintain automatic sprinkler systems. (Fire Safety) | 02-03-2021 / 04-01-2021 |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. (Fire Safety) | 02-03-2021 / 04-01-2021 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Health) | 03-03-2022 / 04-30-2022 |
| Ensure residents have reasonable access to and privacy in their use of communication methods. (Health) | 03-03-2022 / 04-30-2022 |
| 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. (Health) | 03-03-2022 / 04-30-2022 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 03-03-2022 / 04-30-2022 |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Health) | 03-03-2022 / 04-30-2022 |
| 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. (Health) | 03-03-2022 / 04-30-2022 |
| 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. (Health) | 03-03-2022 / 04-30-2022 |
| Provide or obtain dental services for each resident. (Health) | 03-03-2022 / 04-30-2022 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 03-03-2022 / 04-30-2022 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Health) | 03-03-2022 / 04-30-2022 |
| Implement a program that monitors antibiotic use. (Health) | 03-03-2022 / 04-30-2022 |
| Provide properly protected cooking facilities. (Fire Safety) | 03-03-2022 / 04-30-2022 |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. (Fire Safety) | 03-03-2022 / 04-30-2022 |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. (Fire Safety) | 03-03-2022 / 04-30-2022 |
Hospitals Near Fort Bayard Medical Center
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Fort Bayard Medical Center.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
MOUNTAIN VIEW REGIONAL MEDICAL CENTER 4311 EAST LOHMAN AVENUE LAS CRUCES, NM 88011 |
1 |
|
MEMORIAL MEDICAL CENTER 2450 SOUTH TELSHOR BLVD LAS CRUCES, NM 88011 |
2 |
|
THREE CROSSES REGIONAL HOSPITAL LLC 2560 SAMARITAN DRIVE LAS CRUCES, NM 88001 |
Not Available |
|
BHC MESILLA VALLEY HOSPITAL, LLC 3751 DEL REY BOULEVARD LAS CRUCES, NM 88012 |
Not Available |
Medical Professionals Associated with Fort Bayard Medical Center
These are the doctors who are affiliated with Fort Bayard Medical Center. The data is from the most recent period. Historical data is not available.
- LAURA DAVENPORT-REED ( INTERNAL MEDICINE - STATE OF NEW MEXICO )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for Fort Bayard Medical Center
Five different rating results plus detailed inspection numbers and quality measures for Fort Bayard Medical Center.
Covid Infections at Fort Bayard Medical Center
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for Fort Bayard Medical Center
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for Fort Bayard Medical Center
A list of all of the registered owners for Fort Bayard Medical Center. This includes direct and indirect owners and managers.
Noted Deficiencies for Fort Bayard Medical Center
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does Fort Bayard Medical Center compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in SANTA CLARA, NM
Homes that you should consider. A list ranking the best skilled nursing facilities in SANTA CLARA based on their weighted inspection score as of May 01, 2023.
Worst Nursing Homes in SANTA CLARA, NM
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in SANTA CLARA based on their weighted inspection score as of May 01, 2023.
Other Data Periods:
Data on Fort Bayard Medical Center is available for the following periods:
