Inspection Reports for Brookdale at Home® Valencia
300 Valencia Dr SE, Albuquerque, NM 87108, United States, NM, 87108
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Inspection Report
Re-Inspection
Census: 44
Deficiencies: 1
Jan 8, 2024
Visit Reason
The visit was a revisit survey conducted to assess compliance with state regulations for Assisted Living Facilities for Adults, specifically related to custodial drug permits and medication storage.
Findings
The facility failed to ensure that residents who self-administer medications stored them in locked compartments in their rooms, resulting in unsecured prescription, OTC, and narcotic medications observed during the inspection. This deficiency poses a risk of harm, injury, or death if medications are misused or stolen.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure residents who self-administer medications stored them in locked compartments in their rooms, resulting in unsecured medications. |
Report Facts
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Programs | Interviewed confirming unsecured medications | |
| Administrator | Interviewed confirming unsecured medications |
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 6
Jun 14, 2023
Visit Reason
This document is a revisit survey for Brookdale Valencia to verify correction of previously cited deficiencies related to admission/discharge agreements, resident rights, custodial drug permits, housekeeping, and emergency lighting.
Findings
The facility was found deficient in multiple areas including incomplete refund provisions in admission/discharge agreements, unsecured sharps containers, improper medication storage, unsecured oxygen tanks, unsecured hazardous chemicals, and non-functioning emergency lights. Plans of correction with completion dates were provided for each deficiency.
Deficiencies (6)
| Description |
|---|
| Admission/Discharge Agreements did not include a complete refund provision in case of death as required by 7 NMAC 8.2.20 A (5). |
| Sharps containers with contaminated needles, syringes, and lancets were unsecured and accessible to residents, risking harm. |
| Medications, including self-administered medications, were not stored in locked compartments or containers. |
| Oxygen tanks were unsecured and stored improperly, posing safety hazards. |
| Poisonous or flammable substances and chemicals were stored unsecured in resident-accessible areas. |
| Emergency lights throughout the facility, including near exits and laundry rooms, failed to operate during testing. |
Report Facts
Census: 42
Sharps containers observed: 1
Oxygen tanks observed unsecured: 5
Chemicals observed unsecured: 17.4
Paint cans observed unsecured: 3.66
Containers of paint observed unsecured: 16
Motor vehicle cleaning wax observed unsecured: 17.5
Professional strength drain opener observed unsecured: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed deficiencies related to admission/discharge agreements and medication storage during interviews. | |
| Health and Wellness Director | Confirmed sharps container deficiencies and responsible for monitoring medication storage compliance. | |
| Maintenance Director | Responsible for monitoring housekeeping and emergency lighting compliance. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 9
Aug 4, 2022
Visit Reason
The inspection was a full onsite/complaint survey conducted on 08/04/2022 for state requirements according to the 7.8.2 NMAC Regulations for Assisted Living Facilities for Adults. The visit was complaint-related with three complaint intake IDs investigated and found unsubstantiated with no deficiencies cited related to the complaints.
Findings
The facility was found deficient in multiple areas including lack of documentation for supervised training of Direct Care Staff, absence of written personnel policies, incomplete resident admission/discharge agreements regarding refund provisions, missing resident rights poster, failure to review initial resident evaluations, incomplete incident reporting, and unsafe oxygen storage practices. The deficiencies could place residents at risk of harm, injury, or death.
Complaint Details
Complaint Intake IDs NM 51358, NM 56259, and NM 59562 were investigated and found unsubstantiated with no deficiencies cited related to the complaints.
Deficiencies (9)
| Description |
|---|
| Facility failed to document that Direct Care Staff received sixteen hours of supervised training prior to providing unsupervised care. |
| Facility failed to have written personnel policies including qualifications and training policies. |
| Admission/Discharge Agreements did not include a complete refund provision in case of death. |
| Facility did not have a Resident Rights poster visibly posted in the common area. |
| Initial resident evaluations were not reviewed by licensed personnel for 5 of 6 residents. |
| Facility failed to report incidents within required timeframes and conduct timely investigations. |
| Oxygen storage room lacked precautionary signage and had unsecured oxygen cylinders posing safety risks. |
| Emergency lights were not functioning in multiple locations. |
| Facility failed to ensure all windows had screens, exposing residents to insects and debris. |
Report Facts
Residents at risk: 48
Direct Care Staff training hours: 16
Residents whose initial evaluations were not reviewed: 5
Oxygen cylinders unsecured: 12
Emergency lights not working: 4
Completion dates: Multiple corrective action completion dates ranging from August 4, 2022 to September 30, 2022.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed and confirmed lack of documentation and policies; responsible for compliance plans. | |
| Health & Wellness Director | Confirmed resident initial evaluations were not available and responsible for compliance plan. | |
| Business Office Manager | Responsible for auditing Direct Care Staff personnel files and assisting with compliance. | |
| Maintenance Director | Responsible for maintaining emergency lights and compliance with safety plans. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 30, 2020
Visit Reason
The inspection was conducted as a complaint survey to investigate Complaint NM46409 regarding compliance with state regulations for assisted living.
Findings
No deficiencies were cited during the complaint survey, and the complaint was found to be unsubstantiated.
Complaint Details
Complaint NM46409 was unsubstantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 15, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 6, 2020
Visit Reason
Offsite Revisit/Follow-up survey to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited and the facility was found to be in compliance for this survey.
Inspection Report
Routine
Deficiencies: 0
May 27, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
Apr 21, 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
Routine
Deficiencies: 0
Mar 31, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 12, 2020
Visit Reason
The inspection was conducted as a complaint survey related to state requirements for assisted living, specifically Complaint Intake #42349.
Findings
The facility failed to report incidents of unusual occurrence that could threaten resident health, safety, or welfare to the Licensing Authority within 24 hours or the next business day for 2 of 9 residents reviewed. Several falls with injuries were documented but not timely reported.
Complaint Details
Complaint Intake #42349 was unsubstantiated with deficiencies cited. The facility failed to report multiple incidents including witnessed and unwitnessed falls with injuries for residents #5 and #7 within the required timeframe.
Deficiencies (1)
| Description |
|---|
| Failure to report incidents of unusual occurrence to the Licensing Authority within 24 hours or the next business day for residents #5 and #7. |
Report Facts
Residents reviewed for compliance: 9
Residents with unreported incidents: 2
Incident dates for resident #7: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Assisted Care | Confirmed incidents were not reported to Licensing Authority within required timeframe during interview on 03/12/20 |
Inspection Report
Routine
Deficiencies: 0
Mar 12, 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
Routine
Deficiencies: 0
Mar 9, 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
Follow-Up
Deficiencies: 0
Mar 21, 2018
Visit Reason
The visit was a Revisit/Follow-up survey to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
No deficiencies were cited as a result of the Revisit/Follow-up survey. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 7
Dec 14, 2017
Visit Reason
The inspection was a Full-Onsite/Complaint survey completed on 12/14/17 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities. Complaint Intake NM#30419 was unsubstantiated with no deficiencies cited.
Findings
The facility was found deficient in multiple areas including incomplete admission/discharge agreements, lack of nurse review signatures on Individual Service Plans (ISPs), failure to inform residents of their rights to participate in ISP development, improper storage of oxygen cylinders, non-functional emergency lighting, missing and bent window screens, and lack of an annual fire inspection by the Local Fire Authority.
Complaint Details
Complaint Intake NM#30419 was unsubstantiated with no deficiencies cited.
Deficiencies (7)
| Description |
|---|
| Admission/Discharge Agreements for 2 of 6 residents did not state that the agreement may be terminated if an appropriate placement is found for the resident. |
| Individual Service Plans for 6 of 6 residents were not signed or reviewed by a nurse. |
| Residents were not informed of their right to participate in the development of their Individual Service Plans. |
| Oxygen cylinder tanks were improperly stored unsecured and free standing on the floor, posing a safety hazard. |
| Three emergency lights tested in the facility were not working. |
| Multiple operable windows had missing or bent screens, risking insect infestation. |
| The facility failed to provide evidence of an annual fire inspection by the Local Fire Authority. |
Report Facts
Residents reviewed for Admission/Discharge Agreements: 6
Residents with deficient Admission/Discharge Agreements: 2
Residents reviewed for Individual Service Plans: 6
Oxygen cylinder tanks improperly stored: 8
Emergency lights not working: 3
Residents census: 53
Missing window screens: 15
Bent window screens: 12
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 28, 2015
Visit Reason
The inspection was conducted as a complaint survey based on a substantiated complaint (Complaint NM #29667) regarding compliance with New Mexico Requirements for Assisted Living Facilities for Adults.
Findings
The facility failed to revise the individual service plan (ISP) for one of four sampled residents who experienced a change in condition, potentially impacting resident care due to lack of accurate documentation. Specifically, Resident #1's ISP was not updated despite multiple falls and a deteriorating condition, with no special falls prevention program or updated plan documented.
Complaint Details
Complaint NM #29667 was substantiated. The deficiency involved failure to update the ISP for Resident #1 after changes in condition and multiple falls.
Deficiencies (1)
| Description |
|---|
| Failure to revise an individual service plan for a resident who experienced a change of condition. |
Report Facts
Number of sampled residents: 4
Number of falls: 3
Days for ISP development: 10
Months for ISP review: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Interviewed regarding Resident #1's deteriorating condition | |
| Health Services Director | Interviewed regarding failure to update Resident #1's individual service plan | |
| Family member #1 | Interviewed about Resident #1's condition and care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 10, 2014
Visit Reason
A complaint investigation was completed for intake NM00029526 on 09/10/14 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake NM00029526 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 2013
Visit Reason
The inspection was conducted to investigate multiple complaints (intakes NM00028570, NM00028891, NM00028910) related to the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
All complaints investigated on 01/18/13 were found to be unsubstantiated, and no deficiencies were cited.
Complaint Details
Complaints NM00028570, NM00028891, and NM00028910 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 29, 2012
Visit Reason
A complaint investigation was conducted for intake NM00028318 on 02/29/2012 to assess compliance with state regulations for Assisted Living facilities.
Findings
The facility was found to have substantiated deficiencies related to failure to report an incident of staff-to-resident abuse within 24 hours and failure to submit fingerprint cards, application information, and fees for criminal history screening for one staff member. These deficiencies pose risks of continued abuse and hiring staff without proper background checks.
Complaint Details
The complaint was substantiated. The facility failed to report an incident of abuse from staff #101 to resident #1 within 24 hours, reporting it 14 days late. The administrator acknowledged the delay, citing the need for investigation. Additionally, the facility failed to submit required criminal history screening documentation for staff #102.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident of abuse from a staff to a resident within twenty-four (24) hours of the abuse. |
| Failure to send fingerprint cards, application information, and fees to the Criminal History Screening program for one staff member. |
Report Facts
Days late reporting abuse incident: 14
Number of staff files reviewed with deficiencies: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2011
Visit Reason
A complaint investigation was completed for intakes #NM00028246 and #NM00027999 related to NMAC 7.8.2 regulations governing Assisted Living facilities.
Findings
The complaints were found to be unsubstantiated.
Complaint Details
Complaints investigated under intakes #NM00028246 and #NM00027999 were unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 20, 2011
Visit Reason
A complaint investigation was completed for intake NM00027846.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake NM00027846 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Life Safety
Census: 59
Capacity: 100
Deficiencies: 6
Sep 24, 2009
Visit Reason
Life Safety Code survey conducted on 09/24/2009 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure compliance with life safety code requirements including proper storage and securing of oxygen tanks, storage of flammable substances, exit signage illumination, installation of smoke detectors, and conducting fire drills. These deficiencies potentially affect all residents and staff.
Deficiencies (6)
| Description |
|---|
| Oxygen tanks were not secured in appropriate holders in resident apartments. |
| Facility failed to ensure oxygen was stored in accordance with NFPA 99 and Compressed Gas Association standards. |
| Flammable substances (cooking spray) were stored improperly in food storage areas. |
| Exit signs were not clearly visible or illuminated at the front entrance. |
| Smoke detectors were not installed in common areas of assembly. |
| Fire drills were not conducted at least quarterly on every shift to assure preparedness for emergency response. |
Report Facts
Licensed capacity: 100
Census: 59
Oxygen cylinders observed: 2
Cooking spray cans: 12
Staff shifts per day: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding oxygen cylinders, flammable substances storage, exit signage, smoke detectors, and fire drills; acknowledged findings at exit conference on 09/24/09 | |
| Dietary Manager | Interviewed regarding storage of flammable substances; instructed staff to discard excess flammable spray | |
| Wellness Director | Responsible for monitoring compliance with oxygen tank storage | |
| Dining Service Director | Responsible for monitoring compliance with pan coating spray storage |
Inspection Report
Routine
Deficiencies: 0
Oct 8, 2008
Visit Reason
The inspection was conducted to assess compliance with New Mexico regulations governing Adult Residential Care Facilities.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies cited during the inspection.
Inspection Report
Life Safety
Census: 61
Capacity: 100
Deficiencies: 5
Oct 7, 2008
Visit Reason
The inspection was conducted to assess the maintenance of building and grounds, fire protection systems, and compliance with life safety codes including fire alarms, smoke detectors, and sprinkler systems.
Findings
The facility failed to maintain fire protection systems including smoke barriers, doors, and shutters; electrical outlets were not GFIC protected; heat detectors were missing; fire alarm batteries were outdated; and sprinkler heads were dirty and needed cleaning or replacement. These deficiencies potentially affect all residents and staff throughout the facility.
Deficiencies (5)
| Description |
|---|
| Fire protection systems including smoke barriers and doors were not self-closing or automatic closing as required. |
| Electrical outlets within two feet of water supply were not GFIC protected. |
| Heat detector was not present in the kitchen. |
| Back-up batteries in the fire alarm control panel were outdated and not replaced every two years as required. |
| Sprinkler heads in the kitchen had lint, dirt, and grease build up and needed cleaning or replacement. |
Report Facts
Licensed capacity: 100
Census: 61
Sprinkler heads with lint, dirt, and grease: 8
Electrical outlets not GFIC protected: 2
Date of outdated fire alarm batteries: Oct 31, 2003
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Stated items would be removed or replaced and responsible for corrective actions | |
| Dining Service Director | Responsible to ensure kitchen doors remain closed |
Inspection Report
Deficiencies: 1
Nov 5, 2007
Visit Reason
The inspection was conducted to evaluate compliance with water temperature regulations in the facility, specifically to ensure water temperatures were maintained within safe limits in resident bathrooms.
Findings
The facility failed to maintain water temperatures within the required range of 95 to 110 degrees Fahrenheit in resident bathrooms, with recorded temperatures exceeding 110 degrees Fahrenheit. The Executive Director acknowledged the problem during an interview.
Deficiencies (1)
| Description |
|---|
| Water temperatures in resident bathrooms exceeded the maximum allowed 110 degrees Fahrenheit, with measurements ranging from 134.9 to 137.2 degrees Fahrenheit and water temperature logs showing a high of 141.1 degrees Fahrenheit. |
Report Facts
Water temperature: 137.2
Water temperature: 135.7
Water temperature: 134.9
Water temperature: 141.1
Water temperature: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| June W. Hatfield | Executive Director | Acknowledged the water temperature problem during interview on 11/05/07 |
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