Deficiencies per Year
16
12
8
4
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Aug 23, 2021
Visit Reason
The inspection was conducted as a complaint survey completed on 08/31/21 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living. Several complaints (#NM51214, #NM52199, #NM53771) were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
Deficiencies were cited related to medication administration records (MARs) lacking both brand and generic names for medications for multiple residents, posing a risk of harm. Additionally, housekeeping services failed to maintain clean and sanitary conditions in resident bathrooms and bed sheets, exposing residents to potential disease and infection risks.
Complaint Details
Complaint #NM51214, #NM52199, and #NM53771 were investigated and found to be unsubstantiated with no deficiencies cited.
Deficiencies (2)
| Description |
|---|
| Medication Administration Records (MARs) did not include both brand and generic names for medications for 4 residents, risking resident harm due to missing vital information. |
| Resident bathrooms and bed sheets were not maintained clean and sanitary, with visible rust stains, dirty floors, and stained bed sheets observed. |
Report Facts
Residents affected: 4
Residents in Assisted Living Unit: 40
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 26, 2020
Visit Reason
An Offsite Surveillance Complaint survey was conducted related to Covid 19 infection prevention and control.
Findings
No deficiencies were cited and the complaint intake #46227 was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint Intake #46227 was unsubstantiated with no deficiencies cited.
Report Facts
Complaint Intake Number: 46227
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 24, 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
Abbreviated Survey
Deficiencies: 0
Jun 17, 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
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
May 8, 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
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 surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Apr 1, 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 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
Complaint Investigation
Deficiencies: 0
Sep 19, 2019
Visit Reason
The inspection was conducted as a complaint survey related to Complaint #NM 36852.
Findings
No deficiencies were cited during the complaint survey, and the complaint was found to be unsubstantiated.
Complaint Details
Complaint #NM 36852 was unsubstantiated without deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 18, 2017
Visit Reason
Revisit/Follow-up survey conducted to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited as a result of the follow-up survey; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 18, 2017
Visit Reason
The inspection was conducted as a result of a complaint (#NM00030287) to assess compliance with state regulations for assisted living facilities.
Findings
No deficiencies were cited and the facility was found to be in substantial compliance with the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Complaint Details
Complaint #NM00030287 was investigated and found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Follow-Up
Census: 34
Deficiencies: 5
May 12, 2017
Visit Reason
This was a Revisit/Follow-up survey conducted to verify correction of deficiencies cited in the prior survey dated 08/05/2016 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
The facility was found to have multiple uncorrected deficiencies including failure to conduct required Caregivers Criminal History Screening Program for two direct care staff, incomplete and inaccurate resident admission/discharge agreements, incomplete resident evaluations and individual service plans lacking signatures and required content, and electrical safety issues such as lack of GFCI outlets near sinks.
Deficiencies (5)
| Description |
|---|
| Failed to conduct required Caregivers Criminal History Screening Program for 2 of 2 Direct Care Staff sampled. |
| Admission/Discharge Agreement did not indicate termination conditions if appropriate placement found and imposed additional pharmacy fees. |
| Resident evaluations incomplete, missing signatures and dates, and did not address required abilities or status. |
| Individual Service Plans not current or accurate, missing signatures and did not include all resident needs. |
| Electrical outlets near sinks were not Ground Fault Circuit Interrupter (GFCI) protected. |
Report Facts
Residents: 34
Direct Care Staff sampled: 2
Additional monthly pharmacy fees: 275
Additional monthly pharmacy fees: 100
Inspection Report
Routine
Census: 47
Deficiencies: 13
Aug 5, 2016
Visit Reason
A Full-Onsite survey was conducted for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
Deficiencies were cited related to licensing requirements, staff qualifications, admissions and discharge agreements, resident evaluations, individual service plans, emergency handling, custodial drug permits, nutrition, water temperature, electrical system safety, fire clearance, and hospice care compliance.
Deficiencies (13)
| Description |
|---|
| Facility license was not displayed in a conspicuous place for residents, visitors, and staff. |
| Two direct care staff failed to meet Caregiver Criminal History Screening Program and Employee Abuse Registry compliance requirements. |
| Admission/Discharge Agreements for 5 residents lacked accurate and complete information regarding termination and pharmacy choice, including additional fees. |
| Resident evaluations for 5 residents were incomplete and lacked signatures and dates of the nurse reviewer. |
| Individual Service Plans for 2 residents were not current or signed by licensed nurse or physician extender. |
| Facility failed to post emergency phone numbers near public phones accessible to residents, staff, and visitors. |
| Oxygen cylinders were improperly stored unsecured in unventilated closets and residents' living areas without 'Oxygen in Use' signage. |
| Food handlers did not wear hairnets or caps when preparing resident meals. |
| Hot water temperatures in resident rooms, public bathrooms, and beauty shop exceeded the maximum safe temperature of 110°F, risking scald injury. |
| Ground Fault Circuit Interrupter (GFCI) outlets were missing near water sources and washing machines throughout the facility. |
| Facility failed to ensure annual fire inspection by local fire authority was current; last inspection was in February 2015. |
| One direct care staff did not receive required annual 6 hours of hospice-specific training or ongoing psychological support for end-of-life care. |
| Two direct care staff failed to meet Caregiver Criminal History Screening Program and Employee Abuse Registry compliance requirements (duplicate of earlier deficiency). |
Report Facts
Resident census: 47
Additional monthly pharmacy fees: 100
Additional monthly pharmacy fees: 275
Hot water temperature: 121.1
Hot water temperature: 113.9
Hot water temperature: 121.5
Hot water temperature: 118.8
Hot water temperature: 113.9
Hot water temperature: 140.4
Hot water temperature: 160.2
Criminal history screening fee: 74
Criminal history screening fee - FBI: 24
Criminal history screening fee - State: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #1 | Direct Care Staff | Missing Employee Abuse Registry documentation. |
| DCS #2 | Direct Care Staff | Late submission of Employee Abuse Registry and missing Caregiver Criminal History Screening Program letter. |
| DCS #3 | Direct Care Staff | Did not receive required annual 6 hours hospice training or ongoing psychological support. |
| Office Manager | Confirmed missing EARS and CCHSP documentation for DCS #1 and #2. | |
| Administrator | Confirmed multiple deficiencies including license display, admission agreements, hot water temperatures, GFCI outlets, and hospice training. | |
| Health and Wellness Director | Confirmed oxygen tank storage deficiencies. | |
| Maintenance Director | Confirmed hot water temperature issues and oxygen tank storage. | |
| Business Manager | Confirmed no emergency phone numbers posted and staff not wearing hairnets. | |
| Licensed Practical Nurse | Confirmed resident evaluations incomplete and unsigned. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 9, 2015
Visit Reason
A revisit survey was completed for intake NM00029660 on 10/09/15 and for the state requirements of 7.8.2 NMAC, Regulations for Assisted Living.
Findings
The revisit was completed with no deficiencies, all previous deficiencies corrected.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 4
Apr 9, 2015
Visit Reason
The inspection was conducted due to a substantiated complaint (#NM00029660) regarding compliance with New Mexico requirements for Assisted Living for Adults.
Findings
The facility failed to report incidents threatening resident health and safety within required timeframes, failed to secure medications and properly document medication administration, did not post the weekly menu for residents, and had fire/smoke compartment doors propped open compromising safety.
Complaint Details
Complaint #NM00029660 was substantiated based on findings related to incident reporting failures.
Deficiencies (4)
| Description |
|---|
| Failed to report incidents threatening resident health and safety to the Licensing Authority within 24 hours or next business day. |
| Failed to ensure medications were secure and out of reach of residents and failed to document medication assistance on the Medication Administration Record (MAR). |
| Failed to post the weekly menu, including snacks, in a location accessible to residents and families. |
| Failed to ensure fire alarm and closed circuit TV system doors were closed or able to close when the fire alarm system was activated; exit door was propped open allowing residents to exit undetected. |
Report Facts
Residents affected: 59
Residents reviewed for medication compliance: 4
Incident log review period: 01/01/2015 to 03/23/2015
Incident cases not reported: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director (HWD) | Interviewed regarding incident reporting, medication storage, and fire door safety. | |
| Food Service Director (FSD) | Interviewed regarding posting of weekly menu. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 27, 2011
Visit Reason
A complaint investigation was completed for intake #NM00027849 for NMAC 7.8.2 regulations governing Assisted Living facilities.
Findings
The complaint was unsubstantiated for allegation of abuse. No deficient practices were cited as a result of this investigation.
Complaint Details
Complaint investigation for allegation of abuse was unsubstantiated.
Inspection Report
Original Licensing
Census: 44
Capacity: 120
Deficiencies: 10
Sep 3, 2009
Visit Reason
The inspection was an original licensing survey conducted to assess compliance with adult residential care facility regulations, including personnel policies, staffing levels, medication administration, fire safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including lack of ongoing staff training, inadequate staffing levels, missing pet vaccination records, medication administration consent issues, improper hot water temperature maintenance, missing annual fire inspection documentation, failure to recharge fire extinguishers, incomplete fire drill records, and incomplete employee criminal history screening and incident reporting documentation.
Deficiencies (10)
| Description |
|---|
| Failure to ensure ongoing training for all sampled employees. |
| Staffing levels not met on a daily basis, not meeting required direct care staff ratios. |
| Failure to have records of pet vaccinations for assisted living residents. |
| Failure to obtain written consent for medication assistance for sampled residents. |
| Failure to maintain hot water temperature between 95 and 110 degrees Fahrenheit. |
| Failure to maintain documentation of an annual fire inspection. |
| Failure to recharge fire extinguishers as needed. |
| Failure to maintain complete records of monthly fire drills and ensure resident participation. |
| Failure to maintain documentation of criminal history screening for direct care staff. |
| Failure to maintain documentation of incident reporting training and timely submission of caregiver screening. |
Report Facts
Census: 44
Total Capacity: 120
Sampled Employees: 10
Sampled Residents: 10
Fire Extinguishers Needing Recharge: 2
Pet Vaccination Records Missing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Acknowledged multiple findings during interviews | |
| Executive Director | Acknowledged findings related to fire inspection and staffing | |
| Maintenance Director | Interviewed regarding fire extinguisher maintenance and fire drills | |
| Resident Services Director | Acknowledged pet vaccination record findings | |
| Office Manager | Acknowledged findings related to incident reporting and employee records |
Inspection Report
Life Safety
Census: 42
Capacity: 63
Deficiencies: 7
Sep 1, 2009
Visit Reason
Life Safety Code survey conducted on 09/01/2009 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to meet several Life Safety Code requirements including protection of hazardous areas by fire barriers or automatic sprinkler systems, emergency lighting functionality and testing, fire clearance documentation, fire alarm system sensitivity testing, fire extinguisher inspections, and fire drill frequency. These deficiencies potentially affect all residents and staff throughout the facility.
Deficiencies (7)
| Description |
|---|
| Facility failed to assure all hazardous areas are protected by a fire barrier with a 1-hour fire resistance rating or automatic sprinkler extinguishing system as defined per NFPA 101. |
| Facility failed to ensure emergency lighting is operational and tested monthly for at least 30 seconds and annually for 90 minutes with records maintained. |
| Facility failed to keep a record of the annual inspection report of the Local Fire Authority as required by Life Safety Code. |
| Facility failed to ensure the fire alarm system and its components are inspected and maintained according to NFPA 72, including sensitivity testing of smoke detectors. |
| Facility failed to ensure approved smoke detectors were installed in all required areas including assembly areas, dining room, living room, activities room, and kitchen. |
| Facility failed to ensure all portable fire extinguishers are inspected monthly and maintained according to NFPA 10 standards. |
| Facility failed to conduct fire drills at least quarterly on every shift to assure preparedness for emergency response. |
Report Facts
Licensed capacity: 63
Census: 42
Fire alarm system inspection report date: Nov 17, 2008
Last documented local fire authority inspection: Oct 29, 2007
Number of staff shifts per day: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fred Rael | Maintenance Director | Named in multiple deficiency findings and responsible for corrective actions. |
| Charles Runkle | Executive Director | Named in multiple deficiency findings and responsible for corrective actions. |
| Director of Maintenance | Interviewed and acknowledged findings; provided information on staff shifts and fire drills. | |
| Administrator | Acknowledged findings during exit conference and interviews regarding facility use of rooms. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 63
Deficiencies: 3
Aug 22, 2007
Visit Reason
The inspection was an annual life safety code survey conducted on 08/22/2007 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in maintaining and inspecting fire alarms, smoke detectors, automatic fire protection sprinkler systems, and fire extinguishers. Specific issues included disconnected magnetic hold open devices on doors, obstructed fire alarm pull stations, sprinkler heads with lint, grease, and paint buildup, and fire extinguishers not properly maintained or present as required.
Deficiencies (3)
| Description |
|---|
| Failure to ensure fire alarm system and components are maintained and inspected according to NFPA 72; issues included propped open doors with disconnected magnetic hold open devices and obstructed fire alarm pull station. |
| Failure to maintain automatic fire protection sprinkler system in good operating condition; sprinkler heads had lint, grease, and paint buildup. |
| Failure to ensure fire extinguishers are inspected, maintained, and present as required; kitchen hood fire suppression system did not meet UL 300 standard and fire extinguishers were not properly mounted or present. |
Report Facts
Licensed capacity: 63
Census during survey: 37
Inspection date: Aug 22, 2007
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 8, 2007
Visit Reason
Annual inspection to assess compliance with New Mexico regulations governing Adult Residential Care Facilities.
Findings
No deficiencies were cited on 08/07/2007; the facility is in compliance with all New Mexico regulations governing Adult Residential Care Facilities.
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