Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
30 residents
Based on a July 2018 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 0
Date: Jul 24, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were found during the COVID-19 infection prevention and control survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2020
Visit Reason
Offsite surveillance reviews were conducted related to COVID-19 infection prevention and control. Additionally, an offsite complaint investigation was completed.
Complaint Details
Complaint # NM44232 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
No deficiencies were found during the COVID-19 infection prevention and control surveillance. The complaint investigation (Complaint # NM44232) was unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 30, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were found during the COVID-19 infection prevention and control surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 17, 2020
Visit Reason
An Onsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the Covid 19 infection prevention and control survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
This was a revisit survey completed to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the revisit survey.
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 1
Date: Jul 18, 2018
Visit Reason
The inspection was a Revisit survey conducted to assess compliance with state regulations for Assisted Living facilities, specifically focusing on staff training and record maintenance.
Findings
The facility failed to maintain Direct Care Staff (DCS) training files on-site, which poses a risk to all 30 residents if care is provided by staff without documented completion of required supervised and annual training. The House Manager confirmed the absence of documented training files despite some training having been conducted.
Deficiencies (1)
Failure to maintain Direct Care Staff training files on-site as required by regulation.
Report Facts
Resident census: 30
Required supervised training hours: 16
Required annual training hours: 12
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 8
Date: Feb 26, 2018
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to assess compliance with state regulations for assisted living facilities, including investigation of complaint intake NM#30473 which was unsubstantiated.
Complaint Details
Complaint intake NM#30473 was unsubstantiated with no deficiencies cited.
Findings
The facility was found deficient in multiple areas including lack of a full-time administrator, failure to clear staff through the Employee Abuse Registry prior to hire, incomplete staff training, inadequate resident evaluations and individual service plans especially related to hospice care coordination, improper storage of oxygen tanks, lack of monthly fire extinguisher inspections, failure to conduct required fire drills, and medication administration issues including missing physician orders.
Deficiencies (8)
No full-time administrator was available to supervise the facility.
Staff were not cleared by the Employee Abuse Registry prior to hire and fingerprint submissions were late.
Direct Care Staff did not receive the required 12 hours of orientation training.
Individual Service Plans (ISPs) and resident evaluations were not updated or reviewed by a nurse, and did not include hospice care coordination.
Oxygen cylinder tanks were improperly stored with combustibles and lacked required signage.
Fire extinguishers were not inspected monthly as required.
Fire drills were not conducted on every 8-hour period per quarter as required.
Medication Administration Records (MARs) included medications without physician orders.
Report Facts
Residents on census: 30
Staff with incomplete clearance: 3
Direct Care Staff lacking required training: 3
Fire extinguishers: 7
Residents with incomplete evaluations: 7
Residents with incomplete ISPs: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Confirmed lack of full-time administrator, delays in Employee Abuse Registry clearance, and incomplete staff training | |
| Cook | Had no Employee Abuse Registry clearance prior to hire and fingerprints not submitted timely | |
| Direct Care Staff #3 | Had delayed Employee Abuse Registry clearance | |
| DCS #4 | Confirmed medication without physician order for resident #8 |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 10, 2017
Visit Reason
A Revisit/Follow-up survey was completed on 04/10/17 for survey dated 02/21/17 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
There were no deficiencies cited and the facility was found to be in substantial compliance.
Inspection Report
Original Licensing
Census: 3
Deficiencies: 4
Date: Feb 21, 2017
Visit Reason
The inspection was conducted as an initial survey to assess compliance with state requirements for assisted living facilities.
Findings
The facility was found deficient in multiple areas including incomplete admission agreements missing termination clauses, resident evaluations lacking signatures and dates, absence of posted emergency phone numbers, and unsecured medication refrigerator lacking a lock.
Deficiencies (4)
Admission agreements did not include the statement that the agreement may be terminated if an appropriate placement is found for the resident for 3 of 3 residents reviewed.
Resident evaluations for 3 residents lacked dates and signatures of the evaluating licensed nurse or physician extender.
Facility failed to post a list of emergency phone numbers accessible to residents, visitors, and staff.
Medication refrigerator used for medications requiring refrigeration did not have a lock.
Report Facts
Residents reviewed: 3
Residents on census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed deficiencies related to admission agreements and resident evaluations during interview | |
| Lead Caregiver | Confirmed medication refrigerator did not have a lock during observation and interview |
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 29, 2016
Visit Reason
An initial life safety code survey was conducted at the facility on November 29, 2016, at the provider's request. A follow-up onsite revisit survey was conducted on December 7, 2016 to verify correction of previously noted issues.
Findings
The facility was found in substantial compliance with the Life Safety Code Portion of the New Mexico State Regulations for Assisted Living Facilities. Temporary licensure of the facility is recommended.
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