Inspection Reports for
Betty Dare Wellness & Rehabilitation LLC
3101 NORTH FLORIDA AVENUE, ALAMOGORDO, NM, 88310
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
68% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 30, 2025
Visit Reason
The inspection was conducted to investigate complaints related to inadequate care planning, failure to follow physician's orders, and inaccurate medical record documentation for residents with wounds.
Complaint Details
The visit was complaint-related, focusing on wound care deficiencies for residents R #16, R #17, and R #18. The complaint was substantiated by findings of inadequate care plans, failure to follow physician orders, and inaccurate documentation.
Findings
The facility failed to create baseline and comprehensive care plans that included all necessary wound care interventions for residents, failed to follow physician's orders regarding wound care and suture/staple removal, and inaccurately documented wound care treatments in medical records. These deficiencies posed risks of adverse events and inadequate care.
Deficiencies (4)
Failed to create a baseline care plan including necessary wound care information for resident R #17.
Failed to develop a complete care plan with measurable timetables and actions for resident R #16's wounds.
Failed to meet professional standards by not following physician's orders to remove sutures and staples for resident R #16.
Failed to maintain accurate medical records by documenting removal of sutures and staples that were not removed for resident R #16.
Report Facts
Residents reviewed for treatment of wounds: 3
Residents affected by deficiencies: 1
Sutures visible on R #16's knee: 4
Staples visible on R #16's inner left leg near the knee: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed findings related to wound care and documentation deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide activities of daily living (ADL) assistance to a resident.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to provide ADL assistance to resident #24, who is legally blind and hard of hearing, including failure to cut fingernails and failure to assist the resident back to his room after meals.
Findings
The facility failed to provide ADL assistance to resident #24 by not assisting with nail care and not helping the resident back to his room after meals. These deficiencies potentially affected the dignity and health of the resident.
Deficiencies (2)
Failure to assist resident #24 with nail care, resulting in long and jagged fingernails.
Failure to assist resident #24 back to his room after meals, leaving him unattended in the dining room.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Confirmed resident #24 needs assistance with fingernail care. |
| Restorative Nurse Aide | Restorative Nurse Aide | Confirmed resident #24 was left unattended in the dining room and requires assistance. |
| DON | Director of Nursing | Confirmed staff should have assisted resident #24 back to his room after meals. |
Inspection Report
Routine
Census: 61
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage and labeling regulations in the facility.
Findings
The facility failed to secure medications in medication and treatment carts, which were found unlocked and unattended, posing a risk of residents obtaining medications not prescribed to them.
Deficiencies (2)
Medication cart on 100 hallway was unlocked and unattended.
Treatment cart across from nurse's station was unlocked and unattended with medications inside.
Report Facts
Residents present: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #28 | Confirmed medication cart was left unlocked and should be locked when unattended | |
| LPN #8 | Confirmed treatment cart was unlocked | |
| Administrator | Stated expectation that medication and treatment carts be locked when unattended |
Inspection Report
Routine
Deficiencies: 7
Date: May 30, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory standards related to resident care, medication administration, care planning, environment, and medical record keeping.
Findings
The facility was found deficient in multiple areas including failure to notify physicians about medication unavailability and elevated blood sugar levels for a resident, failure to maintain a homelike environment, incomplete and inaccurate care plans, failure to meet professional standards in medication administration and diagnostic testing, inadequate assistance with activities of daily living such as showers, and incomplete medical record documentation.
Deficiencies (7)
Failure to notify physician of resident's medication unavailability and elevated blood sugar levels.
Failure to maintain a homelike environment including unrepaired wall damage and uncovered electrical outlets.
Failure to develop accurate, person-centered comprehensive care plans including functional abilities.
Failure to revise care plans with current resident information such as refusal of care.
Failure to meet professional standards by not entering orders for urinalysis and urine culture, not collecting urine samples, and not administering medications as ordered.
Failure to provide adequate assistance with activities of daily living, specifically showers, resulting in residents receiving fewer showers than scheduled.
Failure to maintain complete and accurate medical records including documentation of provider notification and orders.
Report Facts
Blood sugar levels: 545
Medication administration code 9 occurrences: 12
Shower refusals: 6
Showers received: 2
Residents reviewed for care plans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Interviewed regarding lack of orders and documentation for resident #16's urinalysis and urine culture |
| LPN #27 | Licensed Practical Nurse | Interviewed regarding notification procedures for medication unavailability and high blood sugar |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed care plan deficiencies related to resident #1's refusal of showers |
| DON | Director of Nursing | Interviewed and confirmed multiple deficiencies including care plan issues, notification failures, and shower schedule adherence |
| Corporate Nurse | Corporate Nurse | Confirmed expectations for care plan content and documentation of provider orders |
| Administrator | Facility Administrator | Confirmed environmental deficiencies in resident #1's room |
Inspection Report
Routine
Census: 48
Deficiencies: 9
Date: Aug 15, 2024
Visit Reason
Routine inspection of Betty Dare Wellness & Rehabilitation LLC to assess compliance with regulatory requirements including resident care, medication administration, infection control, and staffing.
Findings
The facility was found deficient in multiple areas including failure to provide requested showers to a resident, inaccurate coding of Minimum Data Set (MDS) assessments, failure to develop comprehensive person-centered care plans for hospice residents, inadequate cleaning and maintenance of oxygen concentrator filters, insufficient RN coverage on certain dates, lack of behavior monitoring for psychotropic medication use, and failure to consistently implement infection prevention and control practices including appropriate use of Personal Protective Equipment (PPE) and hand hygiene.
Deficiencies (9)
Failed to provide requested showers to Resident 100, resulting in feelings of undignified care.
Failed to assess Resident 3 for self-administration of medication, lacking physician orders and care plan documentation.
Failed to ensure clean environment by overusing disinfectant sprays in hallways and resident rooms causing strong odors.
Failed to accurately code MDS for hospice and oxygen therapy for Residents 10, 34, and 17.
Failed to develop a comprehensive person-centered care plan with measurable goals for Resident 10 receiving hospice services.
Oxygen concentrator filters for Residents 21 and 25 were heavily soiled with lint and dirt, not cleaned regularly.
Failed to provide Registered Nurse coverage for at least 8 hours a day on specified dates affecting 48 residents.
Failed to document behavior monitoring for continued use of psychotropic medications for Residents 7 and 19.
Failed to ensure staff wore appropriate PPE for residents on enhanced barrier precautions and failed to clean/disinfect patient equipment and perform hand hygiene consistently.
Report Facts
Residents affected: 18
Resident census: 48
RN coverage missing dates: 4
Psychotropic medications reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Involved in shower scheduling failure, infection control observations, and medication administration |
| Director of Nurses | Director of Nursing (DON) | Provided statements regarding shower scheduling, MDS coding, RN coverage, and infection control practices |
| MDS Coordinator | Minimum Data Set Coordinator (MDSC) | Responsible for MDS coding; admitted to errors in hospice and oxygen therapy coding |
| Infection Preventionist | Infection Preventionist (IP) | Provided infection control training and expectations |
| LPN2 | Licensed Practical Nurse | Observed failing to clean equipment and perform hand hygiene during medication pass |
| Business Office Manager | Business Office Manager (BOM) | Confirmed PBJ submissions and resident census |
Inspection Report
Deficiencies: 1
Date: Oct 10, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to creating baseline care plans for newly admitted residents.
Findings
The facility failed to develop a baseline care plan within 48 hours of admission for one resident (R #156) and did not create a care plan for that resident's pressure ulcer, potentially placing residents at risk of adverse events.
Deficiencies (1)
Failure to develop baseline care plan within 48 hours after admission for resident R #156 and failure to create a care plan for R #156's pressure ulcers.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed during interview that there was no specific care plan for the pressure ulcer of resident R #156. |
Inspection Report
Routine
Census: 50
Deficiencies: 17
Date: Oct 10, 2023
Visit Reason
Routine inspection of Betty Dare Wellness & Rehabilitation LLC to assess compliance with healthcare regulations including resident care, medication management, environment, and safety.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, posting of survey results, notification of family on resident condition changes, environmental odors, incomplete resident assessments, inadequate care planning, lack of discharge planning and summaries, insufficient activity programs for visually impaired residents, unsecured treatment carts, incomplete catheter care, medication regimen issues, improper medication storage, and food storage practices.
Deficiencies (17)
Failed to ensure residents were treated with respect and dignity, including privacy for a visually impaired resident using a urinal.
Failed to post notice of the availability of the most recent state survey in accessible areas.
Failed to notify resident representative of change in condition requiring hospice consult.
Failed to provide a comfortable and homelike environment due to strong urine odor on 100 hall.
Failed to complete comprehensive assessments accurately for several residents.
Failed to complete significant change MDS in a timely manner for hospice resident.
Failed to ensure accurate MDS assessments for residents.
Failed to develop and implement comprehensive person-centered care plans for residents.
Failed to develop an effective discharge plan for a resident.
Failed to ensure discharge summary was completed for a resident.
Failed to provide ongoing activity program adapted for visually impaired resident.
Failed to keep treatment cart locked, posing risk of resident access to medical equipment.
Failed to complete Foley catheter care and flushes as ordered, including missing Toomay syringe flushes.
Failed to act on pharmacy recommendations including lack of physician sign-off and missing maximum dose for acetaminophen.
Prescribed anticoagulant (Apixaban) for hypertension, which is not an appropriate indication.
Failed to properly store medications including unlabeled open bottles, loose tablets in medication carts, and expired medications in Pyxis.
Failed to label and date food items in kitchen pantry and refrigerator, risking foodborne illness.
Report Facts
Residents affected: 28
Residents affected: 50
Medication flushes missed: 8
Medication flushes missed: 3
Medication flushes missed: 5
Medication flushes missed: 2
Expired medications: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #31 | Registered Nurse | Interviewed regarding catheter care and medication cart observations |
| DON | Director of Nursing | Confirmed multiple deficiencies including catheter care, medication regimen, discharge planning, and medication storage |
| CNA #11 | Certified Nursing Assistant | Interviewed about unlocked treatment cart and resident dignity issue |
| CNA #12 | Certified Nursing Assistant | Interviewed about unlocked treatment cart |
| Activity Director | Interviewed about lack of activities for visually impaired resident | |
| Dietary Manager | Interviewed about food labeling and storage practices |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 12, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident neglect, abuse, failure to accommodate resident needs, improper care planning, and infection control issues at Betty Dare Wellness & Rehabilitation LLC.
Complaint Details
The complaint investigation was substantiated regarding abuse of resident R #2 by CNA #1, who slapped the resident's genitals causing pain. The facility also failed in multiple areas of resident care and rights, including dignity, timely assistance, confidentiality, care planning, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with respect and dignity, failure to timely answer call lights, failure to safeguard resident medical records, substantiated abuse of a resident by a staff member, failure to develop and revise comprehensive care plans, and failure to follow proper infection control practices.
Deficiencies (7)
Failed to ensure a resident was treated with respect and dignity, including inappropriate use of briefs and catheter without orders.
Failed to reasonably accommodate resident needs and preferences, including untimely response to call lights and lack of supervision in dining room.
Failed to keep residents' personal and medical records private and confidential; medication cart computer left open with resident information visible.
Failed to protect a resident from physical abuse and mental anguish; substantiated incident of staff slapping resident's genitals.
Failed to develop and implement a comprehensive person-centered care plan, including improper use of briefs and failure to monitor oxygen as ordered.
Failed to revise care plan to reflect resident's non-compliance with oxygen therapy and lack of documentation of interventions.
Failed to follow proper infection control practices; staff member observed moving between resident rooms with same gloves without hand hygiene.
Report Facts
Residents reviewed for neglect: 7
Residents reviewed for abuse: 3
Residents affected by call light delays: 6
Call light wait times: 30
BIMS score: 13
Oxygen saturation: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Interviewed regarding resident R #2's continence and use of briefs | |
| Director of Nursing (DON) | Interviewed multiple times regarding resident care plans, abuse incident, call light response, and infection control | |
| NA #1 | Reported abuse incident involving CNA #1 and resident R #2 | |
| PTA #1 | Witnessed abuse incident and reported to administration | |
| CNA #1 | Staff member who slapped resident R #2 causing abuse | |
| RN #11 | Interviewed regarding oxygen monitoring and documentation for resident R #11 | |
| CNA #22 | Observed failing to remove gloves between resident rooms |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 11, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, activities, transfers, and facility operations at Betty Dare Wellness & Rehabilitation LLC.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination, timely notification of transfers, development and implementation of care plans, provision of activities, access to vision services, restorative nursing care, respiratory care documentation, psychotropic medication use, medication storage, and menu variety.
Deficiencies (10)
Failed to ensure a resident was assisted to bed according to her preferences.
Failed to provide timely notification of transfer or discharge to residents and representatives.
Failed to develop and implement care plans for residents' dementia and fall risk interventions.
Failed to provide activities including 1:1 activities and weekend activities.
Failed to arrange transportation for vision care appointments.
Failed to initiate restorative nursing care to prevent further decrease in range of motion.
Failed to document oxygen saturation, pulse, respirations, lung sounds, and time spent during respiratory treatments.
Failed to ensure psychotropic medications had appropriate diagnoses documented.
Failed to secure medication carts and stored loose medications in medication carts.
Failed to update menus periodically resulting in complaints of lack of variety.
Report Facts
Residents reviewed for choices: 2
Residents affected by choice deficiency: 1
Residents reviewed for discharge notification: 3
Residents affected by discharge notification deficiency: 2
Residents reviewed for care plans: 2
Residents affected by care plan deficiency: 2
Residents reviewed for activities: 10
Residents affected by activities deficiency: 8
Residents reviewed for vision services: 1
Residents affected by vision service deficiency: 1
Residents reviewed for ADL restorative care: 3
Residents affected by restorative care deficiency: 2
Residents reviewed for respiratory care: 1
Residents affected by respiratory care deficiency: 1
Residents reviewed for psychotropic medication: 5
Residents affected by psychotropic medication deficiency: 2
Residents affected by medication cart deficiency: 5
Residents sampled for food complaints: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim DON | Interim Director of Nursing | Interviewed regarding resident bed assistance and restorative nursing care |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident assistance to bed |
| Administrator | Facility Administrator | Interviewed regarding transfer notification and transportation for vision care |
| IDON | Interim Director of Nursing | Interviewed regarding transfer notification and respiratory care documentation |
| CNA #20 | Certified Nursing Assistant | Confirmed bed position for resident #33 |
| Activities Director | Activities Director | Interviewed regarding weekend activities |
| Health Information Manager | Health Information Manager | Interviewed regarding transportation for vision care |
| Business Office Manager | Business Office Manager | Provided email about transportation options |
| LPN #5 | Licensed Practical Nurse | Confirmed medication cart unlocked and loose medications |
| Dietary Manager | Dietary Manager | Interviewed regarding menu repetition and food committee |
| DON | Director of Nursing | Interviewed regarding psychotropic medication diagnoses and medication cart security |
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