Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Jan 13, 2025
Visit Reason
Complaint survey conducted to investigate two complaint intakes for the state requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults.
Findings
No deficiencies were cited during the complaint survey for both complaint intakes investigated.
Complaint Details
Two complaint intakes were investigated and no deficiencies were cited.
Inspection Report
Follow-Up
Census: 71
Deficiencies: 2
Jun 27, 2023
Visit Reason
This was an onsite Revisit/Follow-up survey conducted to verify correction of previous deficiencies related to fire drill documentation as per state requirements of 7 NMAC 8.2, Regulations for Assisted Living for Adults.
Findings
The facility failed to ensure that monthly fire drills included documentation of the number of staff participating and the evacuation time in total minutes for April and May 2023. These deficiencies were uncorrected from a prior survey dated 12/15/22.
Deficiencies (2)
| Description |
|---|
| No documentation of the number of staff participating in the fire drill for April and May 2023. |
| No documentation of the evacuation time in total minutes for April and May 2023 fire drills. |
Report Facts
Resident Census: 71
Survey Date: Jun 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shellie Sims | Executive Director | Signed the report as Executive Director |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 5
Dec 15, 2022
Visit Reason
The inspection was a complaint survey conducted due to complaint intakes #NM55452 and #NM56906, both of which were found to be unsubstantiated but with deficiencies cited related to medication administration and fire safety compliance.
Findings
The facility was found deficient in medication management, including failure to ensure availability of PRN medications for residents, improper medication documentation, and failure to report medication errors. Additionally, deficiencies were found in oxygen cylinder storage and fire safety, including lack of annual fire inspection and incomplete fire drill documentation.
Complaint Details
Complaint Intake #NM55452 and #NM56906 were unsubstantiated but deficiencies were cited related to medication administration and fire safety.
Deficiencies (5)
| Description |
|---|
| Failure to ensure availability of PRN medications for residents, with medication administration records missing from medication carts. |
| Oxygen cylinder tanks were not stored securely or separated from combustible materials, and electrical boxes contained frayed wires. |
| Failure to ensure correct dosage and documentation of medications for residents, including lack of medication error reports and physician notifications. |
| Facility failed to have an annual fire inspection from the local fire authority. |
| Facility failed to conduct monthly fire drills in September and October 2022 and failed to document staff participation and evacuation times for fire drills in November and December 2022. |
Report Facts
Residents on census: 68
Oxygen tanks observed: 5
Oxygen tanks stored with combustible materials: 3
Residents reviewed for medication: 4
Residents whose medication records were reviewed: 68
Residents affected by medication deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Mascarenas | Surveyor | Named as surveyor who evidenced the custodial drug permit deficiency |
| Business Office Manager | Interviewed and confirmed findings related to oxygen tank storage and fire drill records | |
| Licensed Practical Nurse | LPN | Interviewed and confirmed medication availability findings |
| Maintenance Director | Confirmed fire drill records did not include documentation of staff participation or evacuation times |
Inspection Report
Original Licensing
Census: 5
Deficiencies: 9
Jun 3, 2021
Visit Reason
Initial survey completed on 06/03/21 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities, including licensure and compliance with state regulations.
Findings
The facility was found to have multiple deficiencies related to licensure requirements, admission/discharge agreements, individual service plans, resident rights, custodial drug permits, medication refrigerator locks, oxygen storage, nutrition, housekeeping services, and doors. Several deficiencies were noted as not meeting regulatory requirements, potentially placing residents at risk.
Deficiencies (9)
| Description |
|---|
| Assisted Living License was not posted in a conspicuous public place visible to residents, staff, and visitors. |
| Admission/Discharge Agreements lacked required information including termination conditions, refund policy, staffing ratio, and bed hold policy. |
| Individual Service Plans (ISPs) did not include clear goals, expected outcomes, or documentation of expected outcomes. |
| Ombudsman Resident Rights posters were not posted in a conspicuous public place. |
| Medication refrigerators in the Memory Care Unit and medication rooms lacked locks. |
| Oxygen cylinder tanks were stored unsecured and improperly, posing fire and safety hazards. |
| Nutrition services failed to post daily snacks, maintain proper food storage and labeling, and maintain cleanliness and temperature logs. |
| Housekeeping services failed to secure cleaning chemicals and hazardous materials, posing risk to residents. |
| Bathroom pocket doors could not be readily unlocked from inside, posing safety risks in emergencies. |
Report Facts
Residents present: 5
Temporary license duration: 120
Notice period for termination: 15
Notice period for refund policy: 7
Notice period for belongings disposal: 45
Inspection date: Jun 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis C. Trujillo | Administrator | Signed the report and interviewed during inspection confirming findings |
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