Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Betty Dare Wellness & Rehabilitation LLC
Alamogordo, NM · 90 certified beds · Last Life Safety survey August 15, 2024
CMS Certification Number 325061 · first certified January 1992
Ownership
Operated by OPCO SKILLED MANAGEMENT · For profit - Limited Liability company
- New ownershipOwnership changed November 1, 2024 (change of ownership)from THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Position within NM
15 citations — more than 54% of the 68 certified nursing homes in NM. Compared within NM rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (September 2025 to November 2025), and past the point by which nine in ten NM facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in NM are typically surveyed 13–15 months after the last one (median 14), measured over 65 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in NM, and nationally. Surveyors differ markedly between states, so the NM figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in NM | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 11, 2022 | 3 |
| October 10, 2023 | 4 |
| August 15, 2024 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-08-15 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-10-10 |
| E-0007 | Address patient/client population and determine types of services needed. | 1 | 2022-10-11 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-08-15 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-10-10 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-10-10 |
| E-0032 | Provide primary/alternate means for communication. | 1 | 2024-08-15 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2024-08-15 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Smoke Deficiencies 4
- Miscellaneous Deficiencies 3
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Smoke Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (September 29, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (September 29, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (September 29, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 29, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 29, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 29, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 29, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 29, 2024) |
October 10, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 8, 2023) |
October 11, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (December 23, 2022) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (December 23, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 23, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.