Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 5
Oct 8, 2025
Visit Reason
Complaint survey completed for state requirements of NMAC 8.730.14, Regulations for Assisted Living for Adults, investigating complaint intake NM.
Findings
Deficiencies were cited related to failure to provide scheduled activities in the Memory Care unit, failure to post Resident Rights poster, unsecured medications and oxygen tanks, and unsecured poisonous or flammable chemicals in the facility.
Complaint Details
Complaint intake NM was investigated and deficiencies were cited.
Deficiencies (5)
| Description |
|---|
| Failed to ensure activities calendar for Memory Care unit residents was followed as presented, resulting in missed activities for 29 residents. |
| Failed to post Resident Rights poster in the facility's common area. |
| Failed to ensure medications were securely stored in locked compartments and oxygen tanks were secured to prevent accidental damage or dislocation. |
| Failed to ensure poisonous or flammable chemicals were stored in secured areas and not accessible in residential or common areas. |
| Failed to maintain housekeeping supplies and chemicals in locked and secured areas. |
Report Facts
Census: 79
Census: 29
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Schlaffman Phillips | Executive Director | Confirmed no activities offered on certain days and unsecured medications and oxygen tanks |
| Resident Care Coordinator #2 | Confirmed scheduled activities not happening as scheduled in Memory Care unit | |
| DCS #6 | Confirmed no activities in Memory Care unit prior to hiring Activities Assistant #1 | |
| Life Enrichment Director | Confirmed no activities offered on specific dates due to staff absence | |
| Maintenance Director | Will hold in-service training for housekeeping and maintenance staff on security and storage of housekeeping carts |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Jul 30, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to water supply issues and compliance with state regulations for assisted living facilities.
Findings
The facility was found deficient in maintaining adequate hot water temperatures in resident rooms, with water outages and inadequate hot water reported from May to July 2025. Additionally, the facility failed to complete a required re-evaluation for a memory care resident who exhibited physical aggression, potentially putting residents and staff at risk.
Complaint Details
Complaint intake NM was investigated and deficiencies were cited related to water supply and hot water issues. The complaint also involved a memory care resident's aggressive behavior and lack of re-evaluation.
Deficiencies (2)
| Description |
|---|
| Failure to ensure hot water temperature was maintained between 95 and 110 degrees Fahrenheit in resident rooms, resulting in residents being inconvenienced by lack of hot water. |
| Failure to complete a re-evaluation for a memory care resident exhibiting physical aggression to determine if a higher level of care was needed. |
Report Facts
Census: 80
Census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Phillips | Executive Director | Signed laboratory director/provider representative signature on report |
| Memory Care Director | Interviewed regarding failure to re-evaluate aggressive resident | |
| Maintenance Director | Interviewed and confirmed water supply and hot water issues |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 3
Mar 3, 2025
Visit Reason
The inspection was conducted as a complaint survey on 03/03/2025 for the state requirements of NMAC 8.730.14, Regulations for Assisted Living for Adults. Multiple complaint intakes were investigated, with some deficiencies cited.
Findings
The facility failed to provide adequate supervision and assistance with bathing and grooming for several residents, failed to secure cleaning supplies and hazardous chemicals, and failed to maintain cleanliness and odor control in resident rooms. These deficiencies could likely cause harm or illness to residents.
Complaint Details
Multiple complaint intakes were investigated; some complaints were not cited, while others were cited. The deficiencies related to bathing assistance and grooming were cited based on complaint investigations.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure residents #4, #7, and #8 received required assistance with bathing and grooming as per their care plans. |
| Facility failed to ensure cleaning supplies and hazardous chemicals were stored in secured areas and were accessible to residents. |
| Facility failed to ensure room 24 was clean and free from offensive odors, with dried urine stains and strong urine smell present. |
Report Facts
Census: 72
Census: 28
Shower assistance frequency: 2
Shower logs dates: 7
Chemical quantities: 1.85
Chemical quantities: 32
Chemical quantities: 79.3
Chemical quantities: 2.5
Chemical quantities: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryanne Mandel | Executive Director | Signed the plan of correction |
| Memory Care Administrator | Reported concerns about resident #4's hygiene during interview | |
| Direct Care Staff (DCS) #1 | Confirmed laundry room was unlocked and chemicals accessible; confirmed urine stain and cleaning schedule | |
| Life Enrichment Assistant | Confirmed laundry room unlocked and chemicals accessible | |
| Executive Director | Confirmed LOC and tasks for residents #7 and #8 during interview |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 10
Jul 9, 2024
Visit Reason
The inspection was conducted as a Regulation Review Survey and Complaint survey for the state requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults, including complaint investigations with deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to maintain a complete written emergency disaster plan, failure to report and investigate incidents of abuse, neglect, or exploitation, failure to protect residents' rights, failure to ensure medication administration compliance, nutrition, housekeeping, maintenance, and safety issues such as broken window screens and fire extinguisher maintenance. Several residents were identified at risk of harm or exploitation, including financial misappropriation by a staff member who was arrested.
Complaint Details
The complaint investigation involved allegations of medication errors causing harm to a resident's eyes, failure to report incidents, and financial exploitation of residents by a staff member. The investigation substantiated deficiencies related to these complaints, including failure to report incidents timely and financial misappropriation by a Direct Care Staff member who was arrested.
Deficiencies (10)
| Description |
|---|
| Failure to ensure a complete written emergency disaster plan for region/area-wide emergencies. |
| Failure to report and investigate incidents of suspected abuse, neglect, or exploitation in accordance with regulations. |
| Failure to protect resident rights including proper notification, grievance procedures, and freedom from abuse and exploitation. |
| Failure to ensure medication administration compliance including documentation, storage, and administration errors. |
| Failure to maintain nutrition standards including meal service, menu planning, and food storage. |
| Failure to maintain cleanliness and housekeeping standards in resident rooms and common areas. |
| Failure to maintain building and grounds in good repair including broken and missing window screens and damaged ceiling tiles. |
| Failure to maintain fire extinguishers in satisfactory condition and inspected monthly. |
| Failure to ensure security and restricted access in the Memory Care Unit including unsecured windows. |
| Financial exploitation and misappropriation of resident funds by a staff member, resulting in arrest and termination. |
Report Facts
Resident census: 114
Incident report review: 4
Residents at risk of exploitation: 7
Residents involved in financial exploitation findings: 3
Meals per day: 3
Fire extinguishers required: 2
Window screens missing or damaged: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #1 | Direct Care Staff | Named in findings related to financial exploitation, theft, and abuse investigations; arrested and terminated. |
| Registered Nurse Director of Health Services | RN Director of Health Services | Interviewed regarding incident reporting and medication administration findings. |
| Executive Director | Executive Director | Involved in emergency preparedness plan review, incident reporting, and facility oversight. |
| Maintenance Supervisor | Maintenance Supervisor | Confirmed broken and missing window screens and other maintenance deficiencies. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding nutrition and menu compliance findings. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
Oct 26, 2023
Visit Reason
The inspection was a complaint survey conducted to investigate multiple complaint intakes regarding the facility's compliance with regulations for Assisted Living Facilities for Adults.
Findings
The facility was found deficient in updating Individual Service Plans (ISPs) after significant changes in residents' health status and failed to report incidents and investigations timely to the licensing authority. Several incidents involving resident elopement, falls, and lack of proper follow-up and documentation were cited.
Complaint Details
The complaint investigation involved multiple complaint intake IDs. Some complaints were substantiated with deficiencies cited, while others had no deficiencies. Specific incidents included residents found outside the facility unsupervised, falls with delayed assistance, and failure to notify legal representatives or emergency contacts timely. The facility failed to submit required reports within five business days following incidents.
Deficiencies (3)
| Description |
|---|
| Failure to update Individual Service Plans (ISPs) to reflect significant changes in residents' health status. |
| Failure to report incidents of abuse, neglect, or exploitation within required timeframes and submit investigation reports to the licensing authority. |
| Failure to ensure resident rights including safe environment, freedom from neglect, and proper monitoring to prevent elopement. |
Report Facts
Census: 81
Date of survey completion: Oct 26, 2023
Timeframe for ISP implementation: 10
Timeframe for incident reporting: 24
Timeframe for investigation report submission: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Blount | Interim Director | Signed as provider representative on the report. |
| Wellness Director | Interviewed and confirmed findings related to ISPs and incident reporting. | |
| Executive Director | Interviewed and confirmed review of video footage and incident details. | |
| Memory Care Unit (MCU) Director | Interviewed regarding resident elopement and incident details. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 8
Oct 3, 2023
Visit Reason
Complaint survey conducted on 10/03/23 to investigate two complaint intakes with deficiencies cited related to state requirements for Assisted Living Facilities for Adults.
Findings
The facility was found to have multiple deficiencies including inadequate staffing levels, failure to provide assistance with daily living activities, incomplete individual service plans, failure to report incidents timely, resident rights violations, improper custodial drug permits, unsecured oxygen tanks, and damaged or missing window screens. These deficiencies posed risks of harm, injury, or neglect to residents.
Complaint Details
Complaint intake IDs investigated with deficiencies cited. The complaint involved allegations of abuse and neglect, including sexual abuse and improper care. The facility failed to report the incident timely and conduct a thorough investigation.
Deficiencies (8)
| Description |
|---|
| Failed to ensure sufficient Direct Care Staff on duty and available at all times to meet residents' needs. |
| Failed to provide assistance with daily living activities including eating and grooming as scheduled. |
| Individual Service Plans (ISP) were not reviewed or revised timely with significant changes in residents' health status. |
| Failed to report and investigate incidents of suspected abuse or neglect within required timeframes. |
| Resident rights were not fully protected including failure to ensure privacy and freedom from abuse or neglect. |
| Failed to maintain proper custodial drug permits and medication storage requirements. |
| Oxygen tanks were not properly labeled, secured, or stored according to fire safety standards. |
| Operable windows lacked screens in good repair, allowing insects to enter and potentially expose residents to health risks. |
Report Facts
Resident census: 84
Staffing requirement: 1
Staffing requirement: 3
Incident reporting timeframe: 24
Incident investigation timeframe: 5
Window screen minimum operable area: 5.7
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 10
Oct 26, 2022
Visit Reason
Complaint survey conducted for state requirements of 7.8.2 NMAC Regulations for Assisted Living Facilities for Adults, including multiple complaint intakes with substantiated deficiencies.
Findings
The facility failed to ensure direct care staff received required resident rights training, adequate staffing levels, complete admission and discharge agreements including refund policies, proper resident evaluations and individual service plans, timely reporting and investigation of incidents, prohibition of physical restraints, safe medication storage and handling, and proper housekeeping to prevent safety hazards.
Complaint Details
Complaint Intake IDs #NM00055167 (unsubstantiated, no deficiencies), #NM00056573 (substantiated with deficiencies), #NM00057458 (unsubstantiated with deficiencies), #NM00057562 (substantiated with deficiencies), #NM00057702 (substantiated with deficiencies), #NM00061216 (unsubstantiated with deficiencies), #NM00062160 (substantiated with deficiencies).
Deficiencies (10)
| Description |
|---|
| Direct Care Staff failed to receive required resident rights training at orientation and annually with documentation in personnel files. |
| Facility failed to ensure adequate Direct Care Staff on duty on all shifts to provide basic care and supervision based on resident needs. |
| Admission and Discharge Agreements lacked complete refund provisions in case of death as required by regulations and Senate Bill 0335-2013. |
| Resident records lacked progress notes completed by contracted health care agencies for provided services. |
| Resident evaluations were not completed within required timeframes, lacked annual medical evaluations, and were not reviewed or revised by licensed personnel. |
| Individual Service Plans were not updated to address resident needs identified in evaluations and were not reviewed or revised by licensed personnel. |
| Facility failed to report incidents of abuse, neglect, exploitation, injuries of unknown origin, and other reportable incidents to the Licensing Authority within required timeframes and failed to conduct timely investigations. |
| Facility failed to provide a safe and sanitary living environment and prohibited use of physical restraints; residents were found tied or buckled into wheelchairs contrary to care plans and physician orders. |
| Medications were not stored securely; discontinued medications were not inventoried or stored in locked containers; medication room door was often left open; no temperature logs for medication refrigerators; irregularities identified by consulting pharmacist were not resolved. |
| Facility failed to secure poisonous substances and hazardous chemicals from residents, with chemicals and cleaning supplies stored unlocked and accessible in medication rooms without safety data sheets. |
Report Facts
Residents on census: 62
Direct Care Staff minimum requirements: 2
Direct Care Staff minimum requirements: 1
Direct Care Staff minimum requirements: 4
Direct Care Staff minimum requirements: 2
Deficiencies cited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Sammons | Laboratory Director or Provider Representative | Signed the report on 11/17/2022. |
| DCS #10 | Direct Care Staff | Named in staffing and response time deficiencies. |
| Med Aide #1 | Medication Aide | Named in staffing and response time deficiencies. |
| Former DCS #5 | Direct Care Staff | Named in restraint and wheelchair buckling incident. |
| Former Med-Tech #7 | Medication Technician | Witnessed restraint incident and provided statement. |
| Former Med-Tech #9 | Medication Technician | Witnessed restraint incident and provided statement. |
| Former DCS #8 | Direct Care Staff | Witnessed restraint incident and provided statement. |
| Director of Health Services | Director of Health Services | Interviewed regarding multiple deficiencies including incident reporting and medication storage. |
| Administrator | Facility Administrator | Interviewed regarding staffing and medication storage deficiencies. |
Inspection Report
Follow-Up
Census: 65
Deficiencies: 5
Oct 6, 2022
Visit Reason
The visit was an offsite Revisit/Follow-up survey to verify correction of previously cited deficiencies related to staff training, admissions and discharge agreements, incident reporting, medication storage, and fire safety training at Avamere at Rio Rancho.
Findings
The facility was found to have multiple uncorrected deficiencies including failure to provide required staff training, incomplete admission agreements lacking refund upon death policy, failure to report incidents to licensing authority, unsecured medications in a resident's room, and inadequate documentation of fire drills.
Deficiencies (5)
| Description |
|---|
| Failure to ensure Direct Care Staff received required 12 hours of orientation and annual training including fire safety, resident rights, and abuse reporting. |
| Admission/Discharge Agreements for 9 residents did not include a Refund Upon Death policy compliant with NMAC and Senate Bill 0335-2013. |
| Failure to report incidents involving resident #4 to the Licensing Authority as required. |
| Failure to store medications in a secured, locked compartment in resident #6's room who self-administers medications. |
| Failure to maintain documentation of fire drills including time, personnel participating, problems noted, and evacuation time. |
Report Facts
Residents affected: 65
Residents with deficient Admission/Discharge Agreements: 9
Incident reports reviewed: 4
Fire drill records reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Sammons | Executive Director | Signed the report on 10/26/22 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jan 21, 2022
Visit Reason
The inspection was conducted as a complaint survey based on substantiated Complaint Intake NM#54589 regarding compliance with state regulations for Assisted Living facilities.
Findings
The facility failed to provide an updated Admission/Discharge Agreement, failed to give required written notices prior to transferring a resident (R #7) from Assisted Living to the Memory Care Unit, and did not treat the resident and Power of Attorney with proper courtesy and respect. These deficiencies placed the resident and POA at risk of financial hardship and lack of informed consent regarding changes in services and costs.
Complaint Details
Complaint Intake NM#54589 was substantiated with deficiencies cited related to admission/discharge agreements, resident rights, and notification procedures for resident transfer.
Deficiencies (5)
| Description |
|---|
| Failure to provide an updated Admission/Discharge Agreement including changes in services, costs, and material terms prior to resident transfer to Memory Care Unit. |
| Failure to provide fifteen (15) day written notice of Admission/Discharge Agreement termination prior to resident transfer to Memory Care Unit. |
| Failure to provide thirty (30) day written notice regarding changes in cost and material services provided. |
| Failure to treat resident and Power of Attorney with courtesy and respect during transfer and failure to provide advanced written notice of changes in services and costs. |
| Failure to provide fifteen (15) calendar day written notice before room transfer from Assisted Living to Memory Care Unit. |
Report Facts
Days for written notice: 15
Days for written notice: 30
Resident count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Griffith | Laboratory Director or Provider/Supplier Representative | Signed the report on 02/10/2022. |
| Administrator | Interviewed confirming resident transfer without proper notice. | |
| Community Business Office Manager | Sent emails and made calls to resident's POA regarding admission agreement. | |
| Community Executive Director | Responsible for ensuring proper notification and monitoring resident agreements. | |
| Arbor Administrator / Director of Health Services | Responsible for ensuring proper notification and monitoring resident agreements. |
Inspection Report
Routine
Census: 76
Deficiencies: 6
Jan 30, 2019
Visit Reason
The inspection was conducted as an initial survey for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities, to assess compliance with admissions, discharge, pets, custodial drug permits, medication administration, nutrition, water safety, and other regulatory requirements.
Findings
Multiple deficiencies were cited including missing admission/discharge agreements, lack of vaccination records for facility pets, inadequate oxygen storage ventilation, incomplete medication administration records, and failure to maintain proper water temperatures. Plans of correction were submitted with dates for compliance ranging from May to June 2019.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure admission/discharge agreements were completed and contained required information including program narrative and refund for death policy. |
| Facility failed to ensure pets had current vaccinations and vaccination records on file. |
| Oxygen storage room lacked adequate ventilation to the outside air. |
| Medication administration records for several residents did not include both brand and generic names of medications. |
| Dietary staff failed to wash hands properly before handling food, risking spread of illness. |
| Hot water temperatures in resident rooms and public restrooms exceeded regulatory limits. |
Report Facts
Residents on census: 76
Residents reviewed for admission/discharge agreements: 8
Residents missing admission/discharge agreements: 3
Pets in facility: 2
Residents with medication record deficiencies: 4
Residents affected by hot water temperature deficiency: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings related to admission agreements, vaccination audits, oxygen storage ventilation, medication administration, and dietary compliance. |
| Director of Health Services | Director of Health Services | Reviewed medication orders and audited medication charts for compliance. |
| Maintenance Director | Maintenance Director | Received quotes and monitored installation of oxygen storage exhaust fan and water temperature compliance. |
| Dietary Manager | Dietary Manager | Trained staff on handwashing procedures and oversaw dietary compliance. |
| Administrator | Administrator | Interviewed regarding missing admission/discharge agreements and dietary deficiencies. |
| Regional Director | Regional Director | Interviewed confirming missing admission/discharge agreements. |
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