Inspection Reports for
Calibre Post Acute, LLC
2029 SAGECREST AVE, LAS CRUCES, NM, 88011
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
82% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify providers of abnormal vital signs and medication holds, improper use and monitoring of psychotropic medications, failure to develop accurate care plans, failure to administer medications as ordered, failure to provide necessary behavioral health care, and failure to perform pharmacist recommended medication dose reductions.
Complaint Details
The complaint investigation revealed multiple deficiencies related to failure to notify providers of abnormal vital signs and medication holds, failure to ensure psychotropic medications were medically necessary and monitored, failure to develop accurate care plans, failure to administer medications as ordered, failure to provide necessary behavioral health care, and failure to document pharmacist recommendations.
Findings
The facility failed to notify providers of abnormal vital signs and medication holds for residents with hypertension and diabetes, failed to ensure psychotropic medications were medically necessary and adequately monitored, failed to develop comprehensive care plans for depression, failed to administer medications as ordered and notify providers of medication holds, failed to provide necessary behavioral health care and timely psychiatric services, and failed to document clinical rationale for not following pharmacist recommendations for medication dose reduction.
Deficiencies (7)
Failure to notify provider of abnormal vital signs and medication holds for residents with hypertension and diabetes.
Failure to ensure psychotropic medications were medically necessary and adequately monitored, including lack of gradual dose reduction and monitoring for adverse effects.
Failure to develop and implement accurate, person-centered comprehensive care plans for depression including monitoring behaviors and non-pharmacological interventions.
Failure to administer medications as ordered and notify providers when medications were held due to adverse effects or abnormal vital signs.
Failure to provide necessary behavioral health care and timely psychiatric services to residents with behavioral health needs.
Failure to document clinical rationale for not following consultant pharmacist's recommendation for medication dose reduction.
Failure to ensure nursing staff completed mandatory behavioral health training.
Report Facts
Medication hold days: 18
Medication hold days: 19
PHQ-9 depression scores: 0
Escitalopram dose: 20
Trazadone dose: 25
Insulin glargine dose: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Interviewed regarding monitoring and medication administration for R #16. |
| LPN #17 | Licensed Practical Nurse | Interviewed regarding monitoring and medication administration for R #16. |
| LPN #26 | Licensed Practical Nurse | Interviewed regarding monitoring and documentation for R #24's antipsychotic medication. |
| DON | Director of Nursing | Interviewed regarding facility policies and monitoring for residents R #1, R #2, R #9, R #16, and R #24. |
| Medical Director | Medical Director | Interviewed regarding medication management and clinical rationale documentation. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Interviewed regarding psychiatric referrals and monitoring for R #16. |
| Administrator | Facility Administrator | Interviewed regarding staff behavioral health training compliance. |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, care plan accuracy, assessment accuracy, documentation, and staff training at Calibre Post Acute, LLC.
Findings
The facility was found deficient in notifying providers of missed medication doses for resident #25, ensuring accurate Minimum Data Set assessments for resident #16, revising care plans timely for residents #8, #17, and #25, meeting professional standards in medication administration for resident #25, maintaining complete and accurate medical records for residents #8, #17, and #25, and providing behavioral health training to staff.
Deficiencies (6)
Failed to notify provider of missed doses of Amiodarone and Levothyroxine for resident #25 on 06/14/25 and 06/15/25.
Failed to ensure accurate Minimum Data Set assessment for resident #16, inaccurately documenting a fall without injury instead of with injury.
Failed to revise care plans with current resident information for residents #8, #17, and #25, including missing interventions and updates.
Failed to meet professional standards by not administering medications as ordered for resident #25, including failure to notify provider of unavailable medications.
Failed to maintain complete and accurate medical records for residents #8, #17, and #25, including documentation of refusals, falls, and medication availability.
Failed to provide behavioral health training to staff CNA #8, CNA #9, and ADON #1 as required by facility assessment.
Report Facts
Residents reviewed for medication availability: 3
Residents reviewed for MDS assessment accuracy: 3
Residents reviewed for care plan revisions: 3
Residents reviewed for professional standards of practice: 3
Residents reviewed for documentation accuracy: 3
Residents with behavioral health needs: 20
Residents with mental illness diagnoses: 30
Staff without behavioral health training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse #26 | LVN | Named in medication administration and notification deficiency for resident #25 |
| Registered Nurse #27 | RN | Named in medication administration for resident #25 |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan revisions and documentation for residents #8, #17, and #25 |
| Director of Nursing | DON | Interviewed regarding medication notification, care plan revisions, documentation, and staff training |
| Human Resources Representative | Confirmed staff behavioral health training deficiencies |
Inspection Report
Routine
Census: 98
Deficiencies: 9
Date: Feb 20, 2025
Visit Reason
Routine inspection of Calibre Post Acute, LLC to assess compliance with healthcare regulations including care planning, medication administration, activities of daily living assistance, wound care, staffing, food safety, and medical record accuracy.
Findings
The facility was found deficient in multiple areas including failure to create baseline care plans timely, medication administration errors, inadequate assistance with activities of daily living, failure to provide ordered wound care, insufficient staffing leading to delayed resident assistance, lack of nursing competency in catheter care, unsanitary food service conditions, and incomplete medical record documentation.
Deficiencies (9)
Failed to create an accurate baseline care plan within 48 hours of admission for a resident.
Failed to meet professional standards for medication administration, resulting in blood pressure medications not given as ordered.
Failed to provide adequate assistance with activities of daily living for multiple residents, causing psychological distress.
Failed to receive medication needed for treatment of illness due to pharmacy billing approval delays.
Failed to ensure wound care orders were obtained and implemented timely for a resident with pressure ulcers.
Failed to provide sufficient nursing staff to meet resident needs, resulting in delays in toileting, changing briefs, oral care, and showers.
Failed to ensure nursing staff demonstrated competency in changing suprapubic catheters, risking injury to residents.
Failed to store and serve food under sanitary conditions, including unclean floors, dirty deep fryer oil, and failure to perform hand hygiene before assisting a resident with a meal.
Failed to maintain complete and accurate medical records for residents, including documentation of catheter changes and respiratory assessments.
Report Facts
Residents reviewed for ADL care: 6
Residents affected by ADL staffing deficiency: 5
Residents reviewed for medication administration: 4
Residents affected by medication administration deficiency: 1
Residents reviewed for wound care: 1
Residents affected by wound care deficiency: 1
Residents reviewed for nursing competency: 1
Residents affected by medical record documentation deficiency: 2
Residents in facility census: 98
Residents requiring two-person assist: 17
Residents requiring two-person assist with Sara lift: 7
Residents requiring two-person assist on North Unit: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Called pharmacy regarding medication billing for resident #4 but did not notify physician |
| LPN #16 | Licensed Practical Nurse | Day shift nurse for resident #18 who managed respiratory distress and hospital transfer |
| CNA #8 | Certified Nursing Assistant | Assisted resident #8 to bathroom but resident left on toilet for approximately an hour |
| CNA #10 | Certified Nursing Assistant | Reported staffing shortages and residents wetting themselves due to delayed assistance |
| CNA #29 | Certified Nursing Assistant | Assisted resident #24 with meal but failed to perform hand hygiene before resuming assistance |
| ADON | Assistant Director of Nursing | Unable to confirm competency completion for suprapubic catheter changes and confirmed lack of documentation |
| Nurse Educator | Nurse Educator | Confirmed nursing competencies were verbal only without skills check-off or return demonstration |
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Nov 6, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident rights, care planning, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to provide timely transfer and bed hold notifications to residents and their representatives, incomplete Minimum Data Set (MDS) assessments and inaccurate MDS documentation, incomplete and inaccurate care plans, failure to ensure competency evaluations and mandatory training for nursing staff and CNAs, failure to provide prescribed medications timely, inadequate dental care follow-up, unsafe food storage temperatures, malfunctioning call light systems, and inadequate urinary catheter care.
Deficiencies (17)
Failure to notify resident and representative in writing of hospital transfers and appeal rights.
Failure to notify residents and representatives in writing of bed hold policy duration.
Failure to complete comprehensive Minimum Data Set (MDS) assessments timely and accurately.
Failure to develop accurate, person-centered comprehensive care plans reflecting current resident needs.
Failure to conduct interdisciplinary team meetings within 7 days of admission MDS and failure to revise care plans with current resident information.
Failure to provide prescribed medications including Dexcom glucose monitor and Trulicity injections as ordered.
Failure to provide appropriate diabetic care including blood glucose monitoring and insulin administration after hospice discharge.
Failure to complete smoking safety evaluations after residents decided to smoke or had smoking incidents.
Failure to assess for urinary retention after Foley catheter removal and failure to remove Foley catheter after bladder training completion.
Failure to ensure nursing staff and CNAs completed competency evaluations upon hire and annually.
Failure to provide routine medications timely due to pharmacy supply issues.
Failure to implement gradual dose reductions and ensure psychotropic medications were medically necessary.
Failure to provide routine and emergency dental care and follow-up appointments.
Failure to maintain safe refrigerator temperatures for food storage.
Failure to ensure call lights worked at all times in resident bathrooms and bathing areas on the South Unit.
Failure to ensure nursing staff completed mandatory Effective Communication training.
Failure to include performance reviews as part of annual training for CNAs.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 6
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 40
Residents affected: 20
Staff affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Confirmed failure to complete transfer and bed hold notifications and smoking evaluations |
| LPN #17 | Licensed Practical Nurse | Removed Foley catheter from resident R #77 and R #85; confirmed lack of documentation and assessments |
| MDS Coordinator #1 | Minimum Data Set Coordinator | Confirmed incomplete and inaccurate MDS assessments and failure to reinstate insulin after hospice |
| MDS Coordinator #2 | Minimum Data Set Coordinator | Confirmed care plan inaccuracies and lack of interdisciplinary team meetings |
| DON | Director of Nursing | Confirmed multiple deficiencies including lack of competency evaluations, medication administration failures, and training deficiencies |
| ADON #1 | Assistant Director of Nursing | Confirmed refrigerator temperature issues and call light failures |
| ADON #2 | Assistant Director of Nursing | Confirmed expectations for Foley catheter removal and documentation |
| HIS | Health Information Specialist | Confirmed lack of dental visits and follow-up for residents |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 23, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, neglect, or theft and failure to properly investigate allegations of abuse for several residents.
Complaint Details
The complaint investigation focused on allegations of abuse and neglect involving residents #8, #9, and #11. The facility failed to report incidents timely and did not thoroughly investigate the abuse allegations for resident #9. The allegations were not substantiated as documented, but the investigation lacked documentation of interviews with involved parties.
Findings
The facility failed to report injuries of unknown source within two hours to the State Agency for three residents and failed to complete a thorough investigation regarding allegations of abuse for one resident. Additionally, the facility failed to assess a resident for risk of entrapment from bed rails.
Deficiencies (3)
Failed to timely report injuries of unknown source within two hours to the State Agency for residents #8, #9, and #11.
Failed to complete a thorough investigation regarding allegations of abuse for resident #9.
Failed to ensure resident #25 was assessed for risk of entrapment from bed rails.
Report Facts
Residents affected: 3
Residents reviewed for abuse and neglect: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Interviewed regarding marks on resident #9 | |
| CNA #11 | Sent home pending investigation for allegations of abuse for resident #9 | |
| Director of Nursing (DON) | Interviewed about expectations for abuse investigations and bed rail assessments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 3, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure a safe and orderly discharge for resident #22, who was discharged against medical advice after suspected fentanyl use in the facility.
Complaint Details
The complaint investigation focused on resident #22's discharge against medical advice after suspected fentanyl use in the facility. The investigation found the resident left without proper discharge planning, documentation, or issuance of a Notice of Medicare Provider Non-Coverage. Staff told the resident he had to leave AMA, which was confirmed as inappropriate by the DON and Medical Director.
Findings
The facility failed to properly document and manage the discharge process for resident #22, who left against medical advice after suspected substance use. The resident did not have a home to discharge to, required ongoing care, and the facility did not issue required notices or document discharge planning discussions. Staff actions related to the discharge were deemed inappropriate by the Director of Nursing and Medical Director.
Deficiencies (1)
Failed to ensure a safe, orderly discharge for resident #22 discharged against medical advice without proper documentation or discharge planning.
Report Facts
Residents affected: 1
Date of survey completed: Jan 3, 2024
Amount given for hotel and food: 250
Duration resident left facility without permission: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Handled incident involving resident #22 and discharge process |
| Administrator | Administrator | Interviewed regarding resident #22's discharge and facility policies |
| Director of Nursing | Director of Nursing | Confirmed it was inappropriate to tell resident to leave AMA |
| Medical Director | Medical Director | Confirmed staff should only give AMA form to resident who insists on leaving after risks discussed |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 3, 2023
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and failure to provide pharmaceutical, laboratory, and other resident care services at the facility.
Complaint Details
The visit was complaint-related based on allegations of abuse and neglect involving multiple residents. The facility was found to have failed in timely reporting, thorough investigation, and proper care related to these complaints.
Findings
The facility failed to timely report allegations of abuse for multiple residents, failed to thoroughly investigate abuse allegations involving a CNA, failed to provide routine and emergency medications timely for some residents, and failed to obtain ordered laboratory testing causing delays in treatment.
Deficiencies (4)
Failed to timely report allegations of abuse or serious bodily injury to the State Agency within two hours for multiple residents.
Failed to complete a thorough investigation regarding allegations of abuse for 7 residents related to CNA #11.
Failed to ensure pharmaceutical services were met for 2 residents by missing doses of prescribed medications.
Failed to obtain laboratory testing for 1 resident as ordered, causing delay in chemotherapy treatment.
Report Facts
Residents sampled for abuse and accidents: 5
Residents with abuse reporting failures: 4
Residents reviewed for pharmacy services: 3
Residents with pharmaceutical service deficiencies: 2
Residents reviewed for laboratory services: 1
Residents with laboratory service deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #11 | Certified Nursing Assistant | Named in abuse allegations and investigation for pinching residents |
| DON | Director of Nursing | Interviewed multiple times confirming failures in reporting, investigation, and medication issues |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication delivery issues and lab testing |
| Administrator | Interviewed regarding abuse allegations and reporting |
Inspection Report
Routine
Deficiencies: 20
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident accommodations, advance directives accuracy, timely abuse reporting, transfer notifications, care planning, medication administration, staff competency, behavioral health care, pharmaceutical services, medication storage, laboratory services, food safety, immunizations, and annual training for nurse aides.
Deficiencies (20)
Failed to provide a mattress that fit the bed for resident #72, risking accidents.
Failed to ensure accurate completion of New Mexico Medical Orders For Scope of Treatment (MOST Advance Directives) for residents #3 and #53.
Failed to provide a comfortable and homelike environment by not matching paint in resident #8's room.
Failed to timely report allegations of abuse or serious bodily injury to the State Agency for residents #28, #43, #53, and #74.
Failed to provide timely written notice of transfer to residents #3, #55, and #89 and their representatives.
Failed to provide written bed hold policy notice to residents #3, #55, and #89 at time of transfer.
Failed to ensure accurate Minimum Data Set (MDS) assessments for resident #55, omitting UTI treatment.
Failed to develop comprehensive person-centered care plans for residents #34, #53, and #74.
Failed to revise care plan for resident #55 to reflect changes in diet and pressure ulcer treatment.
Failed to care plan hospice/facility care responsibilities for resident #29.
Failed to ensure appropriate catheter use and treatment for UTI for resident #55, including missed antibiotic doses.
Failed to provide trauma informed care for resident #72 with PTSD diagnosis.
Failed to have competency evaluations for nursing staff CNA #23, CNA #24, CNA #25, and LPN #5.
Failed to provide necessary behavioral health care for resident #55, including psychiatric referral.
Failed to provide timely pharmaceutical services, resulting in missed medication doses for residents #55 and #241.
Failed to properly store medications: insulin cart unsecured, loose tablet in medication cart, and missing temperature logs for medication refrigerator.
Failed to provide timely laboratory services for resident #72, resulting in missed chemotherapy appointment.
Failed to maintain sanitary food service conditions including dirty floors, unclean fryer oil and appliances, lack of hairnets, and unlabeled spices.
Failed to ensure resident #28 received or was offered pneumococcal vaccine.
Failed to include performance reviews and facility assessment in annual training for CNAs #26, #27, and #28.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 95
Residents affected: 1
Residents affected: 95
Residents affected: 1
Staff affected: 3
Inspection Report
Routine
Census: 57
Deficiencies: 21
Date: Sep 9, 2022
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity, notification of room changes, access to survey results, grievance handling, transfer and discharge notifications, baseline and comprehensive care planning, dietary order changes without proper approval, dialysis communication, RN staffing, staff training, pharmacy recommendation follow-up, medication labeling, food labeling, facility assessment currency, hospice documentation, infection control practices, COVID-19 testing frequency, vehicle maintenance, and abuse/neglect training.
Deficiencies (21)
Failed to provide dignity covers for Foley catheter bags for 2 residents.
Failed to provide written notice for room/roommate changes for 2 residents.
Failed to ensure residents knew where the most recent survey results were located and accessible.
Failed to demonstrate response and rationale to grievances for 6 residents.
Failed to provide timely written notice of transfer to hospital for 3 residents.
Failed to provide written notice of bed hold policy for 3 residents transferred to hospital.
Failed to develop and implement accurate baseline care plan within 48 hours of admission for 1 resident.
Failed to develop and implement comprehensive care plans for 4 residents including medication and behavioral interventions.
Changed dietary order from mechanical soft to regular consistency without medical provider approval for 1 resident.
Failed to ensure ongoing communication and collaboration with dialysis facility for 1 resident.
Failed to provide full-time RN coverage for at least 8 consecutive hours a day, 7 days a week.
Failed to provide 12 hours of annual training including staff performance review and facility assessment for 3 CNAs.
Failed to follow pharmacy recommendations for 58 residents including documentation and medication orders.
Failed to properly label 9 open over-the-counter medications with open dates in medication cart.
Failed to label and date food items in kitchen and refrigerator.
Facility assessment was not current or revised.
Failed to ensure relevant communication and documentation of hospice services for 1 resident.
Failed to follow proper infection control practices; staff failed to wear masks properly in resident care areas.
Failed to test all staff twice weekly for COVID-19 during outbreak.
Failed to maintain repairs on facility van used for resident transport including air conditioner and seat belts.
Failed to provide abuse, neglect, and exploitation training to 3 LPN staff members.
Report Facts
Residents affected: 57
Residents affected: 13
Residents affected: 58
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Wore surgical mask under N-95 mask in resident care area | |
| Dietary Staff #1 | Observed with N-95 mask below nose in dining room | |
| CNA #10 | Observed not wearing N-95 mask or eye protection in dining room | |
| CNA #11 | Observed with N-95 mask pulled down below chin in dining room | |
| Infection Preventionist | Confirmed staff should wear N-95 masks in resident care areas | |
| Dietary Manager | Confirmed unlabeled and undated food items in kitchen | |
| DON | Director of Nursing | Confirmed multiple deficiencies including pharmacy recommendations, medication labeling, hospice documentation, infection control, COVID testing, and van maintenance |
| Administrator | Confirmed facility assessment not updated, van maintenance issues, and RN staffing | |
| Social Worker | Confirmed resident behavioral issues and roommate problems | |
| Nurse Practitioner | Confirmed diet order change discussion and need for further consult | |
| Speech Therapist | Confirmed resident chewing issues and diet consistency | |
| Maintenance Director | Confirmed van air conditioner repair quote pending approval | |
| ADON | Assistant Director of Nursing | Confirmed lack of annual training and unlabeled medications |
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