Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 9
Aug 28, 2025
Visit Reason
Complaint survey completed on 08/28/25 for the State requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults.
Findings
The facility was found to have multiple deficiencies including operating without a current operator's license, incomplete staff qualifications and training, missing or outdated resident records, lack of recreational activities, unsecured medications, medication administration errors, building maintenance issues, and expired fire extinguishers.
Complaint Details
Complaint Intake NM and were investigated with deficiencies cited.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure the operator's license was maintained and current, resulting in operation as an unlicensed facility. |
| Direct Care Staff failed to comply with pre-employment fingerprinting and Employee Abuse Registry clearance requirements. |
| Direct Care Staff failed to receive required orientation and annual training including fire safety, first aid, infection control, resident rights, and medication assistance. |
| Resident records lacked updated evaluations, Individual Service Plans, physical exams, and complete demographic information for multiple residents. |
| Facility failed to provide or make available recreational and social activities appropriate to residents' abilities and social history. |
| Medications were not stored in a locked compartment or locked room; medication room and cart were left unattended and unlocked. |
| Medication administration did not follow physician orders and MAR documentation; blood pressure and pulse were not checked as required before medication administration. |
| Dining room ceiling and bathroom plumbing, ceiling, and walls were not maintained in good repair; active water leak and water damaged ceiling tiles observed. |
| Fire extinguishers were expired and last inspected in February 2025, failing to meet inspection requirements. |
Report Facts
Resident census: 21
Operator's license expiration date: 2025
Fire extinguisher inspection date: 2025
Medication administration dates: 6
Number of water damaged ceiling tiles: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed operator's license expiration, incomplete staff training records, medication errors, and building maintenance issues. | |
| Resident Coordinator and Assistant Administrator | Confirmed ongoing water leak issue in West hallway bathroom. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 2025
Visit Reason
The inspection was conducted to investigate complaints received by the state regarding the facility's compliance with regulations for Assisted Living Facilities for Adults.
Findings
No deficiencies were cited during the complaint survey conducted on 01/18/25. The complaints investigated did not result in any cited deficiencies.
Complaint Details
Two complaint intakes were investigated and deficiencies were not cited for either complaint.
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 10
Sep 14, 2022
Visit Reason
The inspection was an Initial and Complaint survey completed on 09/14/22, triggered by Complaint Intake ID #NM00050078 which was substantiated with deficiencies cited.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, admissions and discharge agreements, resident records, medication administration, nutrition, housekeeping, fire drills, smoking policies, and safety measures. Deficiencies posed potential risks of harm, injury, illness, or death to residents.
Complaint Details
Complaint Intake ID #NM00050078 was substantiated with deficiencies cited.
Deficiencies (10)
| Description |
|---|
| Staff failed to complete required training and documentation for transportation safety, staff training, and competency for Resident Care Assistants. |
| Admission and discharge agreements lacked complete refund provisions and did not comply with state regulations. |
| Resident records were incomplete or missing required personal, demographic, and medical information. |
| Facility failed to maintain proper reporting of incidents and internal incident reports within required timeframes. |
| Medication administration records were incomplete, missing prescriber information, start dates, and documentation of medication changes. |
| Nutrition services failed to meet USDA dietary guidelines and proper food storage and sanitation requirements. |
| Housekeeping services failed to maintain cleanliness and proper storage of chemicals and food areas. |
| Facility failed to conduct and document monthly fire drills including evacuation times. |
| Smoking areas were not properly designated or maintained with suitable ashtrays. |
| Windows had damaged or missing screens, and the facility failed to protect residents from allergens and rodents. |
Report Facts
Residents identified on census list: 17
Staff training hours required: 16
Staff training hours annually: 12
Refund notice period: 15
Fire drills required: 1
Fire drill duration: 8
Resident records retention: 5
Temperature range: 41
Temperature range: 0
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