Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 27, 2021
Visit Reason
The inspection was conducted as a complaint survey triggered by complaint intake 53745, which was ultimately unsubstantiated.
Findings
The facility failed to prevent an accident involving resident #2 during a transfer, resulting in injury and a setback in therapy progress. The investigation revealed communication issues between therapy and nursing staff regarding the resident's transfer status and improper transfer techniques used by staff.
Complaint Details
Complaint intake 53745 was unsubstantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to prevent an accident for resident #2 during transfer, leading to injury and setback in therapy progress. | SS=G |
Report Facts
Residents reviewed for falls: 3
Residents involved in fall incident: 1
Entries in ADL log sheet: 11
Entries without lift device use: 4
Entries with mechanical lift or transfer aid use: 7
Plan of correction completion date: Sep 21, 2021
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 9
Jun 18, 2021
Visit Reason
The inspection was conducted as an annual recertification survey, complaint investigations, and a COVID-19 Focus Infection Control survey.
Findings
The facility was found to have multiple deficiencies including failure to notify family of incidents, incomplete care plans, inadequate wound care documentation, unsafe transfer practices, incomplete nurse aide performance reviews, medication regimen review deficiencies, medication errors, improper medication storage, and inadequate infection prevention and control measures related to a COVID-19 outbreak.
Complaint Details
Six complaints were investigated: 5 were unsubstantiated and 1 was substantiated with deficiencies.
Severity Breakdown
SS=D: 2
SS=E: 3
SS=F: 3
SS=C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to notify a family member of a resident's accident, resulting in lack of family involvement in care decisions. | SS=D |
| Failed to develop and revise comprehensive care plans with resident or representative input for 2 of 6 residents reviewed. | SS=E |
| Failed to provide necessary treatment and services for pressure ulcers for 2 residents, including lack of consistent wound assessments and documentation. | SS=E |
| Failed to ensure safe transfer assistance for 1 resident, resulting in a fall and injury. | SS=D |
| Failed to complete Nurse Aide Performance Reviews and in-service education for all CNAs. | SS=F |
| Failed to ensure monthly medication regimen reviews were reviewed and acted upon by the physician and lacked policies with appropriate timeframes. | SS=F |
| Medication error rate exceeded 5% due to failure to administer ordered doses correctly for 2 residents. | SS=E |
| Failed to properly label and store medications and medical supplies, including unlabeled opened multi-dose bottles and unlocked medication carts. | SS=C |
| Failed to maintain proper infection prevention and control measures after a staff member tested positive for COVID-19, including delayed facility-wide testing and continued visitation. | SS=F |
Report Facts
Resident census: 45
Medication error rate: 6.45
Number of residents reviewed for care plans: 6
Number of residents reviewed for wound care: 2
Number of residents reviewed for medication administration: 6
Number of complaints investigated: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in transfer and notification deficiency |
| Administrator | Named in family notification and infection control deficiencies | |
| Director of Nursing | DON | Named in care plan, wound care, medication review, and infection control deficiencies |
| Assistant Director of Nursing | ADON | Named in wound care and nurse aide performance review deficiencies |
| Certified Nursing Assistant #1 | CNA | Named in transfer deficiency |
| Occupational Therapist #5 | OT | Named in transfer deficiency |
| Medical Records Coordinator | MRC | Named in wound care deficiency |
| Physician #1 | Physician | Named in medication regimen review deficiency |
| Licensed Practical Nurse #2 | LPN | Named in medication administration deficiency |
| Registered Nurse #2 | RN | Named in medication administration deficiency |
| Certified Nursing Assistant #3 | CNA | Named in medication storage deficiency |
| Corporate Nurse #1 | Corporate Nurse | Named in medication regimen review deficiency |
| Transport Driver #1 | Transport Driver | Named in infection control deficiency |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 1
Jun 16, 2021
Visit Reason
Life safety code recertification survey conducted to assess compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire).
Findings
The facility was found not in substantial compliance due to failure to ensure sprinkler heads were free of foreign materials, specifically lint accumulation behind industrial dryers in the laundry room, which could impair sprinkler function and pose a fire risk.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Sprinkler heads located at the back of drying units in the laundry room were found loaded with lint, indicating failure to maintain sprinkler heads free of foreign materials. | SS=E |
Report Facts
Licensed capacity: 47
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and stated the foreign material (lint) would be removed immediately |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 22, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 02/15/2021 to 02/21/2021, as required by regulation, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 21, 2020
Visit Reason
An unannounced on-site COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Targeted survey were conducted.
Findings
The facility was found to be in compliance with 42 CFR 483.83 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B related to infection control. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 0
Nov 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control survey were conducted on 11/11/20 by Healthcare Management Solutions, LLC on behalf of CMS.
Findings
The facility was found to be in compliance with 42 CFR 483.83 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B related to infection control.
Report Facts
Sample Size: 3
Supplemental: 0
Inspection Report
Routine
Deficiencies: 0
Aug 12, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 10, 2020
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a seven-day period between 07/27/2020 and 08/09/2020, as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 29
Deficiencies: 0
Jul 30, 2020
Visit Reason
An unannounced on-site COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 related to emergency preparedness and infection control. No deficiencies were cited.
Report Facts
Total residents: 29
Inspection Report
Monitoring
Deficiencies: 0
Jul 15, 2020
Visit Reason
An Offsite Surveillance survey was conducted with video related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Monitoring
Deficiencies: 0
Jul 1, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control using video.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Monitoring
Deficiencies: 0
Jun 18, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control using video.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Jun 10, 2020
Visit Reason
An Offsite Surveillance survey was conducted with video related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Monitoring
Deficiencies: 0
Jun 5, 2020
Visit Reason
An Offsite Surveillance survey was conducted with video related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the Offsite Surveillance survey.
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 0
May 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on May 29, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 26
Inspection Report
Routine
Deficiencies: 0
May 27, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control using video.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Deficiencies: 0
May 20, 2020
Visit Reason
An Offsite Surveillance survey was conducted with video related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
May 13, 2020
Visit Reason
An Offsite Surveillance survey with video was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
May 5, 2020
Visit Reason
An Offsite Surveillance survey with video was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Monitoring
Deficiencies: 0
Apr 30, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
The survey was conducted offsite and involved review of video related to Covid 19 infection prevention and control.
Inspection Report
Routine
Deficiencies: 0
Apr 24, 2020
Visit Reason
An Offsite Surveillance survey was conducted on 04/24/20 related to Covid 19 infection prevention and control.
Findings
The survey involved review of video related to Covid 19 infection prevention and control. No specific deficiencies or severity levels were stated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 17, 2020
Visit Reason
An Offsite Surveillance survey was conducted on 04/14/20 and video surveillance on 04/17/20 related to Covid 19 infection prevention and control.
Findings
The survey focused on Covid-19 infection prevention and control measures through offsite and video surveillance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 14, 2020
Visit Reason
An offsite survey was conducted related to COVID-19 and infection control based on Complaint #NM44221.
Findings
The report documents an offsite survey focused on COVID-19 and infection control practices at the facility.
Complaint Details
Complaint #NM44221 triggered the investigation; no substantiation status is provided.
Inspection Report
Routine
Deficiencies: 0
Mar 27, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
The survey focused on infection prevention and control measures related to Covid 19. No specific deficiencies or severity levels were detailed in the report.
Inspection Report
Routine
Deficiencies: 0
Mar 16, 2020
Visit Reason
An Onsite Surveillance survey was conducted on 03/16/20 related to Covid 19 infection prevention and control.
Findings
The report documents a routine onsite surveillance survey focused on Covid 19 infection prevention and control measures.
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 28, 2020
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with 42 CFR Part 483, Subpart B, requirements for Long Term Care Facilities.
Findings
One deficiency was cited as a result of the annual recertification survey completed on 02/28/2020. Specific details of the deficiency are redacted.
Deficiencies (1)
| Description |
|---|
| Deficiency cited as a result of annual recertification survey |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 1
Feb 25, 2020
Visit Reason
The inspection was a life safety code recertification survey conducted to assess compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire).
Findings
The facility was found not in substantial compliance with life safety code requirements due to failure to ensure the fire-extinguishing system protecting the kitchen range hood was inspected monthly as required by NFPA 17A. This deficiency presents a risk of injury to residents using the adjacent dining room.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the fire-extinguishing system protecting the range hood in the kitchen was inspected monthly as required by NFPA 17A. | SS=E |
Report Facts
Licensed capacity: 47
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Administrator | Acknowledged the missing inspection tag during interview | |
| Dietary Manager | Inserviced to ensure monthly inspection of the fire extinguishing system |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 0
Feb 25, 2020
Visit Reason
The inspection was a life safety code recertification survey conducted to assess compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire).
Findings
The facility was found not in substantial compliance with the life safety code requirements during the recertification survey. The facility is Type V construction and fully sprinklered.
Report Facts
Licensed capacity: 47
Census: 47
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 25, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility's compliance with 42 CFR Part 483, Subpart B, requirements for Long Term Care Facilities.
Findings
No deficiencies were cited as a result of the complaint survey. Two complaint surveys (#NM 39586 and #NM 39218) were unsubstantiated with no deficiencies found.
Complaint Details
Two complaint surveys (#NM 39586 and #NM 39218) were unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 5
Jan 31, 2019
Visit Reason
Annual recertification survey conducted to assess compliance with 42 CFR Part 483, Subpart B requirements for Long Term Care Facilities.
Findings
The facility was cited for multiple deficiencies including failure to provide accurate wound assessments, incomplete comprehensive care plans for residents on psychotropic medications, inadequate activities program meeting residents' needs, unnecessary drug regimen with conflicting medication orders, and failure to maintain proper infection prevention and control practices.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide wound assessments for resident #9. | SS=D |
| Failure to develop and implement a comprehensive person-centered care plan for resident #25 receiving antipsychotic and/or psychotropic medications. | SS=D |
| Failure to provide an activities program that meets residents' needs, including activity assessments and scheduling. | SS=E |
| Failure to provide a drug regimen free from unnecessary medications due to conflicting physician orders and excessive acetaminophen dosing for resident #9. | SS=D |
| Failure to maintain proper infection prevention and control practices including lack of negative pressure in laundry and biohazard rooms, absence of cleaning schedules for laundry equipment, inadequate door seals, contamination risks to clean linens, and unlabeled chemical bottles. | SS=F |
Report Facts
Facility census: 47
Deficiency count: 5
Acetaminophen maximum dose: 3000
Acetaminophen ordered dose: 3900
Date of survey: Jan 31, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding wound assessments and infection control practices. |
| Director of Nursing | DON | Interviewed regarding care plans and medication orders. |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication administration and activities program. |
| Staff Member #1 | Interviewed regarding activities program and assessments. | |
| Laundry Staff Member #1 | Interviewed regarding laundry cleaning practices. | |
| Assistant Administrator | Interviewed regarding chemical labeling and laundry practices. |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 0
Jan 29, 2019
Visit Reason
A life safety code recertification survey was conducted to assess compliance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire) during the life safety code recertification survey.
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 1
Jan 29, 2019
Visit Reason
Life safety code recertification survey conducted to assess compliance with Title 42 CFR Part 483.90(a) regarding Life Safety from Fire.
Findings
The facility was not found in substantial compliance with life safety code requirements due to the absence of protective guards on sprinkler heads located in the walk-in freezer, which could lead to physical damage and accidental discharge.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Sprinkler heads in the walk-in freezer were not provided with protective guards to prevent physical damage, risking accidental discharge. | SS=B |
Report Facts
Residents present: 47
Licensed capacity: 47
Sprinkler head height: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Interviewed and stated unawareness of missing sprinkler head guards |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 24, 2018
Visit Reason
The inspection was conducted as a complaint survey triggered by Complaint NM#31925 to assess compliance with 42 CFR Part 483, Subpart B requirements for Long Term Care Facilities.
Findings
The facility was found deficient for failing to report incidents of accidents with injuries to the state licensing agency for 2 of 6 residents reviewed. The complaint was unsubstantiated, but related deficiencies were cited. The facility did not report falls with injuries as required, which could compromise resident safety.
Complaint Details
Complaint NM#31925 was unsubstantiated but related deficiencies were cited regarding failure to report incidents of accidents with injuries to the state licensing agency.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that incidents of accidents with injuries were reported to the state licensing agency for 2 of 6 residents reviewed. | SS=E |
Report Facts
Residents reviewed for incidents/accidents: 6
Residents with unreported incidents: 2
Date of complaint survey: Aug 24, 2018
Date of plan of correction completion: Sep 12, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Interviewed regarding reporting of incidents and understanding of regulations | |
| Assistant Director of Nursing (ADON) | Interviewed regarding resident condition and incident reporting | |
| Administrator | In-serviced by corporate staff on reporting guidelines | |
| Director of Nursing | In-serviced by corporate staff on reporting guidelines |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 5
Jan 11, 2018
Visit Reason
Annual recertification survey conducted to assess compliance with 42 CFR Part 483, Subpart B requirements for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including failure to report and investigate an elopement incident, inadequate comprehensive assessments especially related to activities, failure to provide an ongoing resident-centered activities program, and inadequate supervision of residents at risk for elopement.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to report an incident of resident elopement to the state licensing agency. | SS=D |
| Failure to thoroughly investigate an elopement and report results to the Licensing Authority within 5 days. | SS=D |
| Failure to conduct an activities assessment upon admission for all residents. | SS=F |
| Failure to implement an ongoing resident-centered activities program meeting residents' interests and needs. | SS=E |
| Failure to ensure residents were adequately supervised to prevent elopement. | SS=D |
Report Facts
Residents reviewed for activities: 3
Residents identified on census list: 45
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding elopement reporting and investigation |
| Administrator | Facility Administrator | Interviewed regarding elopement investigation and activities program |
| Director of Nursing | Director of Nursing | Re-educated on reporting process and activities assessments |
| Activities Aide | Activities Aide | Interviewed regarding activities assessments and program |
| Activities Director | Activities Director | Interviewed regarding resident activities and preferences |
| Dietary Manager | Dietary Manager | Interviewed regarding activities and diabetic alternatives |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 0
Jan 3, 2018
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque on 01/03/18 in accordance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire). No deficiencies were cited during the life safety code recertification survey.
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 1
Jan 3, 2018
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque on 01/03/18 in accordance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire) due to failure to ensure annual inspection and servicing of commercial cooking equipment as required by NFPA 96, which could result in fire risk to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure annual inspection and servicing of commercial cooking equipment as required by NFPA 96, presenting a fire risk to residents. | SS=F |
Report Facts
Licensed capacity: 47
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nutritional Services Director | Interviewed and acknowledged unawareness of annual servicing requirement for cooking equipment | |
| Director of the Maintenance / Dietary department | Re-educated on the requirement and compliance to the regulation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 30, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility's compliance with 42 CFR Part 483, Subpart B, requirements for Nursing/Skilled Nursing Facilities.
Findings
No deficiencies were cited as a result of the complaint survey. The complaint was unsubstantiated with no deficiencies found.
Complaint Details
Complaint survey was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility's compliance with 42 CFR Part 483, Subpart B, requirements for Nursing/Skilled Nursing Facilities.
Findings
No deficiencies were cited as a result of the complaint survey. The complaint was unsubstantiated with no deficiencies found.
Complaint Details
Complaint survey was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 2
Jan 27, 2017
Visit Reason
The inspection was an annual recertification survey conducted to assess compliance with 42 CFR Part 483, Subpart B, requirements for Long Term Care Facilities.
Findings
The facility was found deficient in ensuring resident privacy and confidentiality, specifically failing to provide a private setting for assessments and discussions by the physician assistant in the therapy common area. This resulted in confidential health information being overheard by other residents, family members, and staff. The facility also failed to promote dignity and respect for the resident involved, causing feelings of humiliation and embarrassment.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents have the right to be assessed and examined in the privacy of their own room, resulting in confidential health information being overheard in the therapy common area. | SS=E |
| Failure to promote dignity and respect for a resident when health care information was discussed in a common area with other residents and staff present. | SS=D |
Report Facts
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant | Named in findings related to conducting assessments and discussions in the therapy common area | |
| Therapy Director | Confirmed that the PA conducts assessments and discussions in the therapy department while residents receive therapy | |
| Administrator | Provided statements about awareness of PA activities and conducted re-education |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 0
Jan 25, 2017
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque in accordance with Title 42 Code of federal regulations, Part 483, Subpart B; Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Title 42 Code of Federal regulations, 483.70 (a) (Life Safety from Fire). The building is Type V (111) Construction and fully sprinklered.
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 1
Jan 25, 2017
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque on 01/25/17 in accordance with Title 42 Code of federal regulations, Part 483, Subpart B; Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Title 42 Code of Federal regulations, 483.70 (a) (Life Safety from Fire) due to failure to conduct an annual fuel quality test for the emergency diesel generator, which could result in generator failure during a power outage, posing a risk to all 47 residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure an annual fuel quality test was conducted for the electrical back up power supply (emergency diesel generator). | SS=F |
Report Facts
Licensed capacity: 47
Census: 47
Fuel quality test frequency: 1
Generator exercise frequency: 12
Generator exercise duration: 30
Long duration generator exercise interval: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nutritional Services Director | Interviewed and acknowledged unawareness of annual fuel quality test requirement | |
| Maintenance Director | Re-educated to ensure annual fuel quality testing and responsible for compliance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 7, 2016
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility's compliance with 42 CFR Part 483, Subpart B, requirements for Nursing/Skilled Nursing Facilities.
Findings
No deficiencies were cited as a result of the complaint survey. The complaint was unsubstantiated with no deficiencies found.
Complaint Details
Complaint survey completed on 12/07/16 was unsubstantiated with no deficiencies cited.
Inspection Report
Life Safety
Census: 46
Capacity: 47
Deficiencies: 4
Apr 6, 2016
Visit Reason
A life safety code recertification survey was conducted to assess compliance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities, specifically focusing on life safety from fire.
Findings
The facility was found not in substantial compliance with life safety code requirements, including deficiencies related to corridor doors with transfer grills allowing smoke passage, inadequate exterior lighting at exit discharges, incomplete fire alarm system testing and documentation, and lack of maintenance records for fire/smoke dampers.
Severity Breakdown
SS=E: 1
SS=F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Corridor doors to nourishment and medication rooms had 14" x 14" transfer grills allowing passage of smoke. | SS=E |
| Exterior lighting at the 200 corridor exit discharges had single bulbs without backup, risking darkness if a bulb fails. | SS=F |
| Fire alarm system testing and documentation were incomplete, lacking itemized device lists, test results, and battery voltage readings. | SS=F |
| Fire/smoke dampers were not maintained every four years as required by NFPA 90A. | SS=F |
Report Facts
Residents at risk due to door deficiency: 23
Resident census: 46
Licensed capacity: 47
Inspection Report
Life Safety
Census: 46
Capacity: 47
Deficiencies: 0
Apr 6, 2016
Visit Reason
A life safety code recertification survey was conducted at Advanced Healthcare on 04/06/16 in accordance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Title 42 Code of Federal Regulations, 483.70(a) (Life Safety from Fire). The building is Type V (111) construction and fully sprinklered.
Inspection Report
Renewal
Deficiencies: 0
Mar 31, 2016
Visit Reason
The inspection was a recertification survey for compliance with 42 CFR Part 483, Subpart B, requirements for Nursing/Skilled Nursing Facilities, and included investigation of one complaint.
Findings
No deficiencies were cited as a result of the recertification survey. One complaint (NM #29934) was substantiated but resulted in no deficiencies cited.
Complaint Details
One complaint (NM #29934) was investigated and substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 16, 2015
Visit Reason
The inspection was conducted as a complaint investigation survey for Nursing/Skilled Nursing Facilities requirements under 42 CFR Part 483, Subpart B.
Findings
No deficiencies were cited as a result of the complaint investigation. The one complaint investigated (NM #29863) was unsubstantiated with no deficiencies cited.
Complaint Details
One complaint investigated: NM #29863 was unsubstantiated with no deficiencies cited.
Inspection Report
Renewal
Deficiencies: 0
Apr 15, 2015
Visit Reason
The visit was a staggered recertification survey conducted to meet the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
No deficiencies were cited during the survey conducted on 04/15/15.
Inspection Report
Life Safety
Census: 44
Capacity: 47
Deficiencies: 1
Apr 14, 2015
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque on 04/14/15 in accordance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with life safety code requirements due to failure to maintain changes in elevation of walking surfaces on the sidewalk, posing a risk of mis-steps to residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the sidewalk on the north side of the building was properly maintained, with broken concrete and uneven surface posing a risk to residents. |
Report Facts
Licensed capacity: 47
Resident census: 44
Residents at risk: 43
Inspection Report
Re-Inspection
Deficiencies: 2
May 22, 2014
Visit Reason
The inspection was a re-certification survey conducted on 05/22/2014 to assess compliance with 42 CFR Part 483, Subpart B, Requirements for Skilled Nursing facilities.
Findings
Deficiencies were cited related to unnecessary drug use, specifically the use of antipsychotic medication without proper justification for Resident #91, and infection control failures related to contact isolation precautions for Resident #73 with Clostridium Difficile. Plans of correction included discharge of affected patients and systemic changes such as staff inservice and monitoring by the Director of Nursing.
Deficiencies (2)
| Description |
|---|
| Drug regimen is free from unnecessary drugs; failure to justify use of antipsychotic medication Risperidone for Resident #91. |
| Infection control program deficiencies related to preventing spread of infection and contact isolation precautions for Resident #73 with C-Diff. |
Report Facts
Date of survey: May 22, 2014
Date of compliance: Jun 10, 2014
Resident number: 91
Resident number: 73
Facility resident count: 45
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 0
May 20, 2014
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque on 05/20/14 in accordance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities.
Findings
The facility was found in substantial compliance with Title 42 Code of Federal Regulations, 483.70(a) (Life Safety from Fire). The building is Type II construction and fully sprinklered.
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 4
Jul 19, 2013
Visit Reason
The document is a Plan of Correction submitted by Advanced Health Care of Albuquerque following a CMS survey conducted on 07/19/2013. It addresses deficiencies related to care plan implementation, coordination of dialysis services, food storage and preparation, infection control, and cleaning of glucometers.
Findings
The survey found deficiencies in services by qualified persons per care plan, coordination of dialysis care, sanitary food storage and preparation, infection control practices including cleaning of glucometers, and proper labeling of food items. The facility submitted corrective actions including staff education, monitoring plans, and systemic changes to address these issues.
Deficiencies (4)
| Description |
|---|
| Failure to implement the care plan for a resident receiving hemodialysis, including ineffective renal function management and incomplete shunt assessments. |
| Failure to coordinate resident care services with the dialysis center for a resident receiving dialysis. |
| Failure to ensure food was stored, prepared, or served under sanitary conditions, including multiple opened and undated food containers and unclean kitchen equipment. |
| Failure to maintain an infection control program ensuring proper cleaning and disinfection of glucometers between resident use, risking bloodborne pathogen transmission. |
Report Facts
Resident census: 35
Resident census: 45
Dates of compliance: Aug 26, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | RN1 | Named in infection control deficiency related to glucometer cleaning |
| Registered Nurse 2 | RN2 | Named in infection control deficiency related to glucometer cleaning |
| Director of Nursing | DON | Responsible for monitoring hemodialysis patients and glucometer cleaning practices |
| Assistant Director of Nursing | ADON | Interviewed regarding shunt assessments for hemodialysis patients |
| Dietary Manager | DM | Named in food sanitation deficiency and responsible for infection control audits |
| Administrator | Administrator | Signed the Plan of Correction |
Inspection Report
Life Safety
Census: 47
Deficiencies: 5
Jul 15, 2013
Visit Reason
A Comparative Federal Monitoring Survey was conducted at Advanced Healthcare of Albuquerque on July 15, 2013, to assess compliance with Title 42 Code of Federal Regulations, Part 483, including Life Safety Code requirements.
Findings
The facility was found not in substantial compliance with the Life Safety Code, with deficiencies related to smoke barriers, hazardous area protections, smoking regulations, medical gas storage, and oxygen transfer procedures affecting various numbers of residents.
Severity Breakdown
SS=E: 4
SS=C: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Smoke barriers were not continuous and properly protected from penetrations and gaps, allowing smoke movement between compartments, potentially affecting 25 residents. | SS=E |
| Hazardous areas were not properly separated from other areas, with soiled linen and trash containers improperly stored, potentially affecting 19 residents near Room 225. | SS=E |
| Smoking regulations were not fully enforced; smoking receptacles and trash containers were improperly placed, potentially affecting all 47 residents. | SS=C |
| Medical gas storage and administration areas were not safely managed, including an unsecured oxygen cylinder, potentially affecting 16 residents. | SS=E |
| Oxygen transfer procedures lacked proper signage and personal protective equipment, potentially affecting 16 residents. | SS=E |
Report Facts
Residents potentially affected: 25
Residents potentially affected: 19
Residents potentially affected: 47
Residents potentially affected: 16
Facility census: 47
Inspection Report
Renewal
Deficiencies: 0
Jun 13, 2013
Visit Reason
The visit was a recertification survey for the requirements of 42 CFR Part 483, Subpart B, for Nursing Facilities.
Findings
No deficiencies were cited during the survey. One complaint was investigated and found to be unsubstantiated with no deficiencies.
Complaint Details
One complaint (NM# 28923) was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 1
Jun 12, 2013
Visit Reason
A life safety code recertification survey was conducted at Advanced Health Care of Albuquerque on 06/12/13 in accordance with Title 42 Code of Federal Regulations, Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with the life safety code standard due to failure to ensure the circuit breaker dedicated to the fire alarm system was mechanically protected, identified with a red marking, and labeled 'FIRE ALARM CIRCUIT CONTROL'. This posed a risk to all 47 residents and staff in the event of fire or emergency.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure the circuit breaker dedicated to the fire alarm system was mechanically protected, identified with a red marking, and labeled 'FIRE ALARM CIRCUIT CONTROL'. |
Report Facts
Licensed capacity: 47
Census: 47
Inspection Report
Life Safety
Census: 47
Deficiencies: 4
Jun 18, 2012
Visit Reason
A Comparative Federal Monitoring Survey was conducted at Advanced Health Care of Albuquerque on June 18, 2012, to assess compliance with Title 42, Code of Federal Regulations, Part 483, specifically focusing on Life Safety from fire.
Findings
The facility was found non-compliant with the Life Safety Code, including deficiencies in smoke barrier doors, smoke barriers, hazardous area separations, and emergency power supply system maintenance. Specific issues included doors lacking astragals, gaps allowing smoke passage, unprotected openings, and missing placards on generators.
Severity Breakdown
SS=E: 3
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Doors protecting corridor openings did not resist the passage of smoke; double doors to Physical Therapy lacked astragals and had gaps allowing smoke passage. | SS=E |
| Smoke barriers failed to provide at least a one-hour fire resistance rating and had unprotected openings including a wire in the smoke barrier wall. | SS=E |
| Hazardous areas were not properly separated with fire-rated barriers and doors, potentially affecting 20 residents near the Hall 1 Mechanical Room. | SS=E |
| Emergency power supply system lacked proper placard and no smoking sign; generator fuel supply did not have a placard or no smoking sign; weekly inspections and maintenance were not assured. | SS=C |
Report Facts
Residents affected: 20
Residents census: 47
Monthly rounds: 6
Generator exercise time: 30
Inspection Report
Renewal
Deficiencies: 1
May 11, 2012
Visit Reason
The inspection was conducted as a re-licensure survey for the requirements of 7.9.2 NMAC for Long Term Care Facilities.
Findings
The facility failed to thoroughly investigate and submit a complete report regarding the misappropriation of a resident's property, specifically a missing $45 cash and credit card. The investigation was incomplete and delayed, presenting a risk of potential harm to residents.
Complaint Details
The investigation was triggered by a complaint regarding Resident #257 whose $45 cash and credit card were stolen by an employee. The facility failed to complete the investigation and submit required reports to the state agency.
Deficiencies (1)
| Description |
|---|
| Failure to thoroughly investigate and report misappropriation of resident's property, including missing $45 cash and credit card. |
Report Facts
Date of survey completion: May 11, 2012
Date of compliance: Jul 18, 2012
Number of audit times: 12
Amount stolen: 45
Amount fraudulently charged: 308.28
Date of incident report: Apr 10, 2012
Date of police report: Apr 10, 2012
Date of police department offense report: Apr 10, 2012
Date of administrator interview: May 9, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #2 | Identified as unlawfully taking Resident #257's credit/debit card and making fraudulent charges | |
| Administrator | Reviewed regulations and stated plans for monthly audits and reporting |
Inspection Report
Re-Inspection
Deficiencies: 6
May 11, 2012
Visit Reason
This report documents a recertification survey conducted on 05/11/2012 for Advanced Health Care of Albuquerque, including investigations of two substantiated complaints (#NM28196 and #NM28457).
Findings
Deficiencies were cited related to residents' rights and notice of rights, investigation and reporting of allegations of abuse and misappropriation of property, development and implementation of abuse/neglect policies, PASRR requirements for mental illness and mental retardation, treatment and care for special needs including oxygen use, and drug storage and labeling. Corrective actions and systemic changes were planned with compliance dates set for 07/18/2012.
Complaint Details
Two complaints (#NM28196 and #NM28457) were substantiated with deficiencies related to residents' rights and misappropriation of property.
Deficiencies (6)
| Description |
|---|
| Failure to inform residents of their rights and provide notice of discontinuation of skilled services. |
| Failure to thoroughly investigate and report allegations of misappropriation of property within required timeframes. |
| Failure to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property. |
| Failure to coordinate assessments and obtain PASRR clearance for residents with mental illness or mental retardation prior to admission. |
| Failure to ensure residents receive proper treatment and care for special needs including oxygen therapy. |
| Failure to employ a licensed pharmacist and maintain proper drug records and storage, including controlled medications. |
Report Facts
Date of survey completion: May 11, 2012
Date of compliance: Jul 18, 2012
Number of residents discharged: 3
Amount stolen: 45
Amount stolen: 308.28
Number of residents observed with portable oxygen cylinders: 15
Number of oxygen cylinders found empty: 4
Number of vials in locked medication box: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #2 | Identified as unlawfully taking resident #257's credit/debit card and fraudulently signing sales receipts | |
| Director of Nursing | Director of Nursing | Performed audits and verified medication storage and oxygen therapy procedures |
| Administrator | Administrator | Reviewed regulations and reported findings related to misappropriation of property investigations |
Inspection Report
Life Safety
Deficiencies: 0
May 10, 2012
Visit Reason
Life Safety Code recertification survey conducted to meet the requirements of 42 CFR Part 483, Subpart B, for Long-Term Care Facilities.
Findings
No deficiencies were cited during the Life Safety Code recertification survey conducted on May 10, 2012.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 1
Feb 16, 2011
Visit Reason
The inspection was an annual recertification survey conducted to assess compliance with New Mexico Regulations Governing Long Term Care Facilities.
Findings
The facility was found deficient for failing to submit fingerprints for criminal history screening within 20 calendar days of employment for 4 of 5 sampled employees, potentially affecting all 46 residents by not preventing the hire of caregivers possibly barred from employment.
Deficiencies (1)
| Description |
|---|
| Failure to ensure fingerprints for Criminal History Screening were submitted within 20 calendar days of employment for 4 of 5 sampled employees. |
Report Facts
Number of residents potentially affected: 46
Number of sampled employees with fingerprint submission issues: 4
Inspection Report
Renewal
Deficiencies: 3
Feb 16, 2011
Visit Reason
The inspection was a recertification survey completed on 02/16/11 for the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in conducting comprehensive assessments of residents receiving psychoactive medications and in infection control practices, including preventing the spread of Clostridium Difficile infection. The quality assessment and assurance committee was also found deficient in identifying and correcting quality deficiencies.
Deficiencies (3)
| Description |
|---|
| Failure to ensure residents receiving psychoactive medications were advised of risks and benefits and assessed for side effects. |
| Failure to establish and maintain an infection control program to prevent spread of infection and contamination, including proper isolation and cleaning procedures for patients with C-Diff. |
| Failure to maintain a quality assessment and assurance committee that identifies and corrects quality deficiencies. |
Report Facts
Patient numbers discharged: 2
Patient numbers discharged: 3
Audit percentage: 25
Date of compliance: Mar 26, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Stated no monitoring of side effects on January's MAR and monitored lab tests for abnormalities |
| Director of Nursing | Director of Nursing | Responsible for auditing patients weekly and reporting findings at Q.A. meetings |
| Administrator | Administrator | Responsible for coordinating QAA meetings and reporting findings |
| Housekeeping Manager | Housekeeping Manager | Stated facility changed cleaning product to Oxiver and discussed its effectiveness |
| License Practical Nurse #1 | Licensed Practical Nurse | Observed stating Resident #344 was admitted with C-Diff and wore gloves in therapy |
| Physical Therapist | Physical Therapist | Stated Resident #344 would be in therapy but was unsure why |
| Medical Records Manager | Medical Records Manager | Attended training on Oxiver and stated no claim that product takes care of C-Diff |
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 6
Feb 9, 2011
Visit Reason
The inspection was a Life Safety Code recertification survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for Long-Term Care Facilities.
Findings
The facility was found noncompliant with the NFPA 101 Life Safety Code standards due to issues with the fire alarm system, sprinkler system, and transferring of oxygen. Deficiencies included a fire alarm system in trouble mode, frozen sprinkler pipes, batteries not replaced on schedule, a sprinkler head falling from the ceiling, and improper signage and installation related to oxygen transfer.
Deficiencies (6)
| Description |
|---|
| Fire alarm system was in trouble mode and not maintained in accordance with NFPA 72. |
| Two batteries within the main fire alarm control panel had not been replaced since 11/25/08. |
| Sprinkler system was not properly installed and operational; sprinkler head in kitchen was falling from ceiling. |
| Facility failed to ensure water-filled automatic fire sprinkler system piping was protected from freezing, causing system piping to freeze. |
| Light switch in oxygen transfer room was installed less than required 5 feet above floor. |
| Oxygen transfer room lacked proper signage indicating transfer of liquid oxygen is occurring. |
Report Facts
Residents present: 47
Licensed capacity: 47
Inspection date: Feb 9, 2011
Inspection Report
Life Safety
Census: 47
Capacity: 47
Deficiencies: 7
Feb 9, 2011
Visit Reason
The inspection was a Life Safety Code survey conducted on February 9, 2011, to assess compliance with 7 NMAC 9.2 State Requirements for Long Term Care Facilities.
Findings
The facility was found noncompliant with the fire alarm system requirements, including issues with the fire alarm system being in trouble mode, batteries not replaced, and a sprinkler head falling from the ceiling. The facility failed to ensure proper maintenance and operation of the fire alarm and sprinkler systems, affecting all residents and staff.
Deficiencies (7)
| Description |
|---|
| Fire alarm system was in trouble mode upon arrival; annunciator panel indicated 'Fault, System I/O's By Passed.' |
| Batteries within the main fire alarm control panel had not been replaced since 11/25/08. |
| Sprinkler head in the kitchen was falling from the ceiling and was not mounted flush to the monolithic ceiling; surrounding drywall showed cracking and peeling. |
| Light switch in the liquid oxygen transfer room was installed at 44 inches from the floor instead of the required minimum of 60 inches. |
| Facility failed to ensure the fire alarm system and its components, including batteries, were maintained in accordance with NFPA 72 standards. |
| Facility failed to ensure the sprinkler system was properly installed, operational, and protected from freezing, resulting in a frozen sprinkler pipe in the kitchen. |
| Facility failed to ensure transferring of liquid oxygen was conducted in an approved location with proper signage. |
Report Facts
Licensed capacity: 47
Census: 47
Date of survey: Feb 9, 2011
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 13, 2011
Visit Reason
The inspection was conducted as a complaint investigation for New Mexico Requirements for Long Term Care Facilities.
Findings
No deficiencies were cited as a result of the complaint investigation completed on 01/13/11. One complaint was investigated and found to be unsubstantiated.
Complaint Details
One complaint (NM#27593) was investigated and was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 13, 2011
Visit Reason
The inspection was conducted as a complaint investigation for one complaint (NM#27593) related to the requirements of 42 CFR part 483 subpart B for Long Term Care Facilities.
Findings
No deficiencies were cited during the complaint investigation, and the complaint was found to be unsubstantiated.
Complaint Details
One complaint was investigated (NM#27593) and was unsubstantiated.
Inspection Report
Life Safety
Census: 42
Capacity: 47
Deficiencies: 7
Mar 16, 2010
Visit Reason
The inspection was conducted as a Life Safety Code survey for State Requirements for Long-Term Care Facilities under 7 NMAC 9.2 on March 16, 2010.
Findings
The facility demonstrated noncompliance with State Requirements for Long-Term Care Facilities related to the fire alarm system inspection, sprinkler system inspection frequency, fire drills, emergency power generator testing, and laundry room ventilation. Several deficiencies were noted that could potentially affect all residents, staff, and occupants.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure the fire alarm system was inspected by a professional company at least once every twelve months as required by NFPA 72. |
| Facility failed to provide written policies and procedures for the fire alarm system being out of service for more than 4 hours within a 24-hour period. |
| Facility failed to ensure the wet and dry automatic sprinkler systems were inspected quarterly as required by NFPA 25, resulting in only annual inspections. |
| Facility failed to ensure fire drills were conducted quarterly on each shift as required by NFPA 101. |
| Facility failed to ensure combustion and ventilation air for fuel-fired commercial clothes dryers were properly separated from the laundry room ventilation air. |
| Facility failed to ensure emergency power generator sets were tested monthly for at least 30 minutes under load and cold starts as required by NFPA 110. |
| Facility failed to ensure specific gravity testing of generator batteries was conducted monthly as required by NFPA 99 and NFPA 110. |
Report Facts
Licensed capacity: 47
Census: 42
Date of survey: Mar 16, 2010
Fire alarm inspection frequency: 12
Fire drill frequency: 4
Generator test duration: 30
Inspection Report
Renewal
Census: 334
Deficiencies: 1
Mar 16, 2010
Visit Reason
The inspection was conducted as a relicensure survey for renewal of the facility's license, specifically to meet the requirements of Long Term Care Facilities 7 NMAC 9.2.
Findings
The facility was found deficient in ensuring that newly hired employees were screened for tuberculosis infection prior to beginning work, affecting all 5 sampled employees reviewed. The deficiency had the potential to affect all residents in the facility.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that newly hired employees were screened for tuberculosis infection prior to beginning work. |
Report Facts
Residents admitted: 334
Sampled employees: 5
Days after hire to TB screening: 36
Days after hire to TB screening: 16
Days after hire to TB screening: 8
Days after hire to TB screening: 14
Days after hire to TB screening: 4
Inspection Report
Re-Inspection
Deficiencies: 5
Mar 16, 2010
Visit Reason
This inspection report documents a recertification survey conducted on 03/11/2010 for a Skilled Nursing Facility, Advanced Health Care of Albuquerque, to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to provide proper Notice of Medicare Provider Non-Coverage to residents, incomplete comprehensive assessments, lack of care plans for falls, medication administration errors exceeding 5%, and incomplete clinical records. Plans of correction were submitted with systemic changes and monitoring procedures.
Severity Breakdown
F 156: 1
F 272: 1
F 279: 1
F 332: 1
F 514: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide residents with proper Notice of Medicare Provider Non-Coverage forms and denial letters. | F 156 |
| Failure to conduct comprehensive assessments accurately reflecting residents' history of falls. | F 272 |
| Failure to develop comprehensive care plans addressing residents' needs, including fall prevention. | F 279 |
| Medication administration error rate exceeded 5%, with errors in administering medications to residents. | F 332 |
| Failure to maintain complete, accurate, and accessible clinical records for residents. | F 514 |
Report Facts
Residents discharged affected by deficient practice: 379
Residents sampled for Notice of Medicare Provider Non-Coverage: 3
Residents sampled for comprehensive assessment: 29
Admissions potentially affected by deficient comprehensive assessment: 334
Medication administration error rate: 7.55
Residents potentially affected by medication errors: 45
Residents sampled for clinical record accuracy: 29
Inspection Report
Life Safety
Census: 42
Capacity: 47
Deficiencies: 6
Mar 16, 2010
Visit Reason
Life Safety Code recertification survey conducted to assess compliance with NFPA 101 fire safety standards for a long-term care facility.
Findings
The facility failed to ensure fire drills were conducted quarterly on each shift, failed to ensure the fire alarm system was inspected annually, failed to inspect wet and dry sprinkler systems quarterly as required, failed to ensure combustion and ventilation air for laundry dryers was properly separated, failed to test emergency generator batteries monthly, and failed to have written policies for sprinkler and fire alarm systems being out of service for more than 4 hours.
Deficiencies (6)
| Description |
|---|
| Fire drills were not conducted quarterly on each nursing shift, exceeding the 90-day interval requirement. |
| Fire alarm system was not inspected annually as required; no records available to confirm inspection. |
| Wet and dry automatic sprinkler systems were inspected only annually instead of quarterly as required by NFPA 25. |
| Combustion and ventilation air for fuel-fired commercial clothes dryers was not separated from laundry room ventilation air by walls or partitions. |
| Emergency generator batteries were not tested monthly for specific gravity as required. |
| Written policies and procedures were not in place for sprinkler and fire alarm systems being out of service for more than 4 hours within a 24-hour period. |
Report Facts
Licensed capacity: 47
Census: 42
Deficiency completion date: All corrective actions have a compliance date of 2010-04-16.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding fire drills, fire alarm system, sprinkler system, generator testing, and acknowledged findings at time of exit. | |
| Administrator in Training | Observed sprinkler system inspection records and acknowledged findings. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 14, 2009
Visit Reason
The inspection was conducted as a complaint survey for a Skilled Nursing Facility under 42 CFR part 483, Subpart B, triggered by complaints #NM00027301 (not substantiated) and #NM00027227 (substantiated).
Findings
The facility failed to notify residents and their family members or legal representatives in writing of the reasons for transfer or discharge, and failed to provide contact information for the State ombudsman for 5 of 5 sampled residents. The deficiency had the potential to affect all residents, particularly short term residents.
Complaint Details
Complaint #NM00027301 was not substantiated with deficiencies. Complaint #NM00027227 was substantiated with deficiency F203 related to transfer and discharge notification requirements.
Deficiencies (1)
| Description |
|---|
| Failed to ensure that the resident and a family member or legal representative were notified in writing of the reason for transfer or discharge and provided contact information for the State ombudsman for 5 of 5 sampled residents. |
Report Facts
Sampled residents: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 14, 2009
Visit Reason
The inspection was conducted as a complaint survey for the Requirements for Long Term Care Facilities 7.9.2 NMAC.
Findings
No deficiencies were cited as a result of the complaint survey. One complaint was not substantiated and one complaint was substantiated with no deficiency.
Complaint Details
Complaint #NM00027301 was Not Substantiated with no deficiency. Complaint #NM00027227 was Substantiated with no deficiency.
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