Inspection Report
Follow-Up
Census: 60
Deficiencies: 2
Sep 26, 2025
Visit Reason
The visit was an offsite Revisit/Follow-up survey conducted to assess compliance with state requirements for Assisted Living for Adults, specifically related to custodial drug permits and medication storage.
Findings
The facility was found deficient in properly storing oxygen cylinder tanks securely and conducting narcotic reconciliation audits daily after every shift. These deficiencies posed a risk of harm to residents if oxygen tanks were to fall or if medication audits were not performed consistently.
Deficiencies (2)
| Description |
|---|
| Failed to ensure oxygen cylinder tanks were stored securely, protected from accidental damage or dislocation. |
| Narcotic reconciliation audits were not performed daily after every shift as required. |
Report Facts
Resident Census: 60
Date of inspection: Sep 26, 2025
Number of oxygen tanks not racked: 3
Total oxygen tanks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Colton Risley | Executive Director | Signed the report and mentioned as Executive Director responsible for auditing compliance |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
Jun 26, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to regulatory compliance at an assisted living facility, specifically addressing complaints with and without deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to post the activities calendar, failure to post emergency phone numbers near public telephones, medication misappropriation related to PRN medications, improper storage and handling of oxygen tanks and narcotic counts, and expired fire extinguishers. Corrective actions and plans of correction were documented for each deficiency.
Complaint Details
Complaint Intake NM # was investigated with no deficiencies cited for one complaint and with deficiencies cited for another complaint.
Deficiencies (5)
| Description |
|---|
| Failed to ensure that the activities calendar for June 2025 was posted where residents could view. |
| Failed to ensure that a list of emergency phone numbers was posted near the public telephones in the facility. |
| Failed to ensure one resident was free from medication misappropriation; narcotic bubble pack was tampered with and replaced with other medications. |
| Failed to ensure oxygen cylinder tanks were stored securely and narcotic reconciliation counts were completed as required. |
| Failed to ensure fire extinguishers were inspected and not expired; one extinguisher was expired as of 4/25/25. |
Report Facts
Resident Census: 22
Number of unsecured oxygen tanks observed: 6
Number of pills tampered with in bubble pack: 8
Number of fire extinguishers required: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Confirmed medication tampering, fire extinguisher expiration, and narcotic count deficiencies; involved in corrective actions |
| Care Coordinator | Care Coordinator | Confirmed lack of activities calendar posting and emergency phone number postings |
| Maintenance Manager | Maintenance Manager | Removed and replaced expired fire extinguishers; responsible for ongoing audits |
Inspection Report
Follow-Up
Census: 45
Deficiencies: 1
Feb 24, 2024
Visit Reason
This onsite revisit/follow-up survey was conducted to assess compliance with state requirements for assisted living facilities, specifically addressing housekeeping services and sanitation issues.
Findings
The facility failed to maintain clean and sanitary common living areas and bathrooms, with multiple observations and interviews confirming a strong smell of urine and dirty floors. Housekeeping practices were insufficient to eliminate offensive odors, posing a risk to residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure common living areas and bathrooms were kept clean and sanitary at all times. |
Report Facts
Resident Census: 45
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 2
Nov 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to report and investigate incidents of resident abuse, neglect, or exploitation in accordance with state regulations.
Findings
The facility failed to report an incident involving a resident's fall and injury to the Licensing Authority within the required 24 hours and did not conduct a thorough internal investigation or submit a follow-up report within five business days. Additionally, the facility failed to maintain clean and sanitary common living areas and bathrooms, resulting in strong urine odors in multiple areas.
Complaint Details
Complaint Intake ID was investigated with deficiencies cited. The complaint involved a resident who fell and was injured, with delayed staff response and failure to report and investigate the incident as required. The complaint was substantiated based on record review and interviews.
Deficiencies (2)
| Description |
|---|
| Failure to report resident incident to Licensing Authority within 24 hours and failure to conduct internal investigation and submit follow-up report within five business days. |
| Failure to maintain clean and sanitary common living areas and bathrooms, resulting in strong urine odors and unsanitary conditions. |
Report Facts
Census: 25
Staff response time: 30
Staff response time: 45
Incident reporting timeframe: 24
Investigation submission timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Confirmed resident's unwitnessed fall and acknowledged failure to report and investigate incident | |
| Housekeeper | Confirmed strong urine odor in bathrooms and laundry rooms | |
| Direct Care Staff (DCS) #3 and #4 | Confirmed strong smell of urine in corridor and bathroom | |
| New Maintenance Technician | Reported carpets were shampooed last week but need cleaning again | |
| Direct Care Staff (DCS) #1 | Reported resident with memory issues peeing on carpets |
Inspection Report
Follow-Up
Deficiencies: 6
Sep 19, 2023
Visit Reason
The visit was a revisit/follow-up survey completed to verify correction of previously cited deficiencies related to staff training, resident evaluation, individual service plans, and building maintenance for an assisted living facility.
Findings
The facility was found to have multiple partial uncorrected deficiencies including lack of documentation for staff training hours, incomplete resident evaluations and individual service plans within required timeframes, and maintenance issues such as drywall penetrations and missing smoke detectors. Plans of correction with completion dates were provided for each deficiency.
Deficiencies (6)
| Description |
|---|
| Failure to ensure Direct Care Staff received 16 hours of supervised training prior to providing unsupervised care. |
| Resident evaluations were not completed within 15 days prior to admission. |
| Individual Service Plans (ISP) were not developed and implemented within 10 calendar days of admission. |
| Walls and ceilings were not maintained in good repair; drywall penetrations were observed. |
| Smoke detectors were missing in dining areas, corridors, and kitchen. |
| Automatic fire sprinkler system was not properly maintained; sprinkler heads were missing or improperly fitted. |
Report Facts
Supervised training hours required: 16
Resident evaluation timeframe: 15
ISP development timeframe: 10
Residents at risk: 8
Smoke detectors observed missing: 4
Facility sprinkler heads missing: multiple
Inspection Report
Routine
Deficiencies: 0
Jul 21, 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
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 29, 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
Apr 2, 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 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
Annual Inspection
Census: 13
Deficiencies: 16
Jan 27, 2020
Visit Reason
The inspection was a full onsite annual survey for state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility was found deficient in multiple areas including staff qualifications and training, resident evaluations and individual service plans, handling of resident funds, emergency preparedness, incident reporting, resident rights, medication management, nutrition services, maintenance of building and grounds, fire safety equipment, hospice care, and memory care unit requirements.
Deficiencies (16)
| Description |
|---|
| Failure to ensure all Direct Care Staff had clearance from the Employee Abuse Registry prior to hire and timely submission of Caregiver Criminal History Screening applications. |
| Direct Care Staff did not receive all required supervised, orientation, and annual trainings. |
| Resident evaluations were not completed within 15 days prior to admission, nor reviewed/updated every 6 months or with significant changes. |
| Individual Service Plans were not developed within 10 days of admission nor reviewed/revised every 6 months. |
| Facility failed to obtain written consent to manage resident funds for residents whose funds were handled by the facility. |
| Emergency phone numbers were not posted near public telephones accessible to staff, residents, families, and visitors. |
| Facility failed to report incidents such as falls causing injury and elopements to the Licensing Authority within 24 hours or next business day. |
| Resident rights were not posted in a conspicuous place including phone numbers for Incident Management Hotline and State Ombudsman; telephones were not located or accessible for private conversations. |
| Medications for some residents were not available on hand as ordered. |
| Facility failed to maintain sanitary conditions in dietary services including uncovered garbage containers, lack of posted weekly menus, and failure to check food temperatures. |
| Walls and ceilings had multiple drywall penetrations and water damage with mold, and storage areas blocked access to electrical panels. |
| North emergency exit sign was not illuminated and did not light up when tested. |
| Smoke detectors were not installed in corridors or main gathering areas; heat detector was not installed in kitchen area. |
| Fire extinguishers were not inspected annually or monthly as recommended by the manufacturer. |
| Direct Care Staff failed to receive required annual hospice care training including specific training for hospice residents. |
| Memory Care Unit deficiencies included lack of required dementia/Alzheimer's training for staff, missing team meetings with PCP for ISPs, missing pre-admission assessments and physician orders for secured environment placement, and residents unable to independently access secured outdoor area due to keypad lock. |
Report Facts
Residents at risk: 13
Direct Care Staff: 3
Direct Care Staff: 3
Direct Care Staff: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #2 | Direct Care Staff | Named in findings for lack of Employee Abuse Registry clearance, missing training, and hospice care training |
| Office Manager | Interviewed regarding staff files and training | |
| Director of Nursing | Provided census and confirmed findings | |
| Administrator | Interviewed regarding facility conditions and policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate Complaint Intake NM#38649 regarding compliance with state regulations for Assisted Living Facilities.
Findings
No deficiencies were cited during the complaint survey, and the complaint was found to be unsubstantiated.
Complaint Details
Complaint Intake NM#38649 was unsubstantiated. No deficiencies cited.
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 2
Jan 12, 2016
Visit Reason
Investigation survey conducted for complaint NM29901 regarding construction issues at the facility.
Findings
The complaint was unsubstantiated. The facility was found not in substantial compliance with New Mexico State Regulations for Assisted Living Facilities due to ongoing construction without approved construction drawings and failure to maintain separation between construction areas and residents, potentially risking physical harm to residents.
Complaint Details
Complaint NM29901 regarding no hot water due to construction was unsubstantiated. However, deficiencies related to construction and safety were cited.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure construction drawings were submitted for review and approval prior to commencement of construction, remodeling, relocations, additions or renovations to existing buildings. |
| Facility failed to ensure separation from construction area and residents was in place during final stages of construction on the 3rd floor, risking physical harm to residents. |
Report Facts
Residents present during inspection: 6
Days for construction commencement: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Advised of complaint and confirmed renovations on 3rd floor; stated all permits and plan approvals had been received and were on site. | |
| Contractor | Stated separation was in place during removal and installation of new walls but not during final stages of construction. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 12, 2016
Visit Reason
Investigation survey conducted on 01/12/16 for complaint NM29901.
Findings
The complaint of no hot water due to construction was unsubstantiated. The facility was found not in substantial compliance with New Mexico State Regulations for Assisted Living Facilities, and other deficiencies were cited due to ongoing construction.
Complaint Details
Complaint NM29901 was investigated and found to be unsubstantiated.
Deficiencies (2)
| Description |
|---|
| No hot water due to construction |
| Other deficiencies cited due to ongoing construction |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 17, 2014
Visit Reason
The inspection was conducted as a complaint investigation survey completed on 04/17/14 for the New Mexico Requirements for Assisted Living Facilities for Adults, triggered by Complaint # MN29383 which was substantiated.
Findings
The facility failed to report unwitnessed falls for several residents to the state Department of Health as required, increasing the risk of abuse or neglect by caregivers. Additionally, the facility failed to conduct criminal history screenings for 15 caregivers employed for over 20 days, raising concerns about potential harm to residents.
Complaint Details
Complaint # MN29383 was substantiated based on the findings of failure to report incidents and failure to conduct required criminal history screenings.
Deficiencies (2)
| Description |
|---|
| Failure to report all suspected cases or known incidents of resident abuse, neglect, or exploitation, specifically unwitnessed falls of residents not reported to the state Department of Health. |
| Failure to conduct criminal history screening for 15 caregivers employed at the facility for over 20 days. |
Report Facts
Residents with unreported falls: 6
Caregivers without criminal history screening: 15
Total residents at risk: 70
Caregivers on updated list: 58
Caregivers without clearance: 22
Caregivers without clearance over 20 days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Larios | Executive Director | Reviewed incident reporting requirements, provided updated caregiver list, and verified employment and clearance status during interviews. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2013
Visit Reason
A complaint investigation was completed for intake NM00029171 on 8/21/13 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 NM00029171 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2013
Visit Reason
A complaint investigation was completed for intake NM00028456 on 04/24/13 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was substantiated with no deficiencies cited.
Complaint Details
Complaint intake NM00028456 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2011
Visit Reason
A complaint investigation was completed for intake NM00028014.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake NM00028014 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 38
Capacity: 40
Deficiencies: 4
May 11, 2010
Visit Reason
The inspection was an annual survey conducted for the Life Safety Code portion of the New Mexico Regulations Governing Requirements for Assisted Living Facilities.
Findings
The facility failed to ensure exit signs were illuminated and visible in normal and emergency modes, fire alarm pull stations were obstructed, fire alarm system batteries were outdated, and fire drills were not conducted quarterly on every shift as required.
Deficiencies (4)
| Description |
|---|
| Exit signs at the north exit and front entrance failed to illuminate in both normal and emergency modes. |
| Fire alarm pull station located at the south exit was obstructed by a chair and not easily accessible. |
| Six batteries within the main fire alarm control panel had not been replaced since 06/08/06. |
| Facility failed to conduct fire drills at least quarterly on every shift; no evidence of a drill for the 2nd shift between 12/14/09 and 04/07/10. |
Report Facts
Licensed capacity: 40
Census: 38
Batteries not replaced: 6
Fire drill shifts missing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged findings related to exit signs, fire alarm pull station obstruction, battery replacement, and fire drill deficiencies. | |
| Program Manager | Acknowledged findings related to exit signs, fire alarm pull station obstruction, battery replacement, and fire drill deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 8
May 11, 2009
Visit Reason
The inspection was conducted as a complaint investigation to review deficiencies related to personnel training, medication administration, custodial drug permits, fire clearance and inspections, and related regulations at Sunrise of Albuquerque.
Findings
The facility was found to have multiple repeat deficiencies from a prior 3/19/2009 survey, including failure to ensure ongoing staff training, incomplete medication administration records, lack of custodial drug permits, failure to maintain annual fire inspections, and inadequate reporting of medication errors to physicians. Corrective actions and training plans were outlined with completion dates.
Complaint Details
This was a complaint investigation triggered by deficiencies noted in a prior survey dated 3/19/2009. The deficiencies were repeat findings from that survey.
Deficiencies (8)
| Description |
|---|
| Failure to ensure ongoing training for 20 of 20 facility employees. |
| Failure to ensure assistance was provided to residents in obtaining necessary medication. |
| Failure to maintain accurate and current medication administration records for multiple residents. |
| Failure to ensure medications, including PRN medications, were administered and documented according to physician orders. |
| Failure to report medication errors to residents' physicians for 6 of 10 sampled residents. |
| Failure to conduct ongoing fire and safety training for 11 of 20 facility employees. |
| Failure to maintain documentation of an annual fire inspection for 2008. |
| Failure to ensure required annual training for incident reporting and intake processing for 20 of 20 staff. |
Report Facts
Facility employees lacking ongoing training: 20
Residents sampled for medication assistance: 10
Residents sampled for medication administration record review: 6
Facility employees lacking fire and safety training: 11
Date of prior survey with repeat deficiencies: Mar 19, 2009
Inspection Report
Original Licensing
Deficiencies: 10
Mar 19, 2009
Visit Reason
The inspection was conducted as an original licensing survey for Sunrise of Albuquerque, to assess compliance with state regulations for adult residential care facilities.
Findings
The facility was found deficient in multiple areas including personnel training, custodial drug permit compliance, medication administration, fire safety training, fire inspections, and related regulations. Several deficiencies were noted regarding documentation, training, medication errors, and fire safety procedures.
Deficiencies (10)
| Description |
|---|
| Failure to ensure ongoing training for 20 of 20 facility employees in required personnel policies and procedures. |
| Failure to ensure assistance was provided to 1 of 9 sampled residents in obtaining necessary medication. |
| Failure to ensure oxygen cylinders were secured in a locked container. |
| Failure to ensure medications were administered as ordered and medication errors were reported to physicians for 3 of 9 sampled residents. |
| Failure to ensure all caregivers had names and initials listed on Medication Administration Records. |
| Failure to maintain documentation of an annual fire inspection for 2008. |
| Failure to ensure ongoing fire and safety training for 11 of 20 facility employees. |
| Failure to maintain documentation of fire drills including evacuation times and participation. |
| Failure to maintain documentation of Employee Abuse Registry checks for 3 of 20 sampled employees. |
| Failure to ensure required annual training for Incident Reporting was conducted for 20 of 20 sampled employees. |
Report Facts
Facility employees lacking required training: 20
Sampled residents affected: 9
Sampled residents with medication errors: 3
Facility employees lacking fire safety training: 11
Sampled employees missing Employee Abuse Registry documentation: 3
Sampled employees missing Incident Reporting training: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #17 | Acknowledged medication errors and missing documentation on Medication Administration Records. | |
| Staff #3 | Mentioned in relation to missing training and medication assistance. | |
| Staff #18 | Mentioned in relation to missing names and initials on Medication Administration Records. |
Inspection Report
Annual Inspection
Census: 30
Capacity: 40
Deficiencies: 7
Mar 19, 2009
Visit Reason
The inspection was conducted as part of an annual survey for the Life Safety Code portion of the New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in maintaining the building and grounds, including failure to test emergency generator batteries, lack of proper signage for fuel supply, inadequate emergency lighting, exit signage, fire clearance inspections, and fire alarm sensitivity testing. These deficiencies potentially affect all residents, staff, and visitors throughout the facility.
Deficiencies (7)
| Description |
|---|
| Failure to ensure specific gravity testing of emergency generator batteries as per NFPA 110. |
| No identifying placard for fuel supply for the generator. |
| Failure to ensure emergency electrical system maintenance in accordance with NFPA 99, NFPA 110, and NFPA 30. |
| Failure to ensure periodic testing of the emergency lighting system; emergency battery backup lights failed to illuminate when tested. |
| Failure to ensure exit signs and directional signs are displayed with continuous illumination as required by NFPA 101. |
| Failure to keep a record of the annual fire inspection report from the local Fire Authority. |
| Failure to provide documentation of fire alarm system sensitivity testing and failure to ensure smoke detectors function reliably. |
Report Facts
Licensed capacity: 40
Census: 30
Inspection date: Mar 19, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding testing and documentation requirements for emergency generator batteries and emergency lighting system. | |
| Maintenance Supervisor | Provided facility file records related to smoke detector sensitivity testing. | |
| Life Safety Code Surveyor | Conducted the inspection and observed deficiencies. |
Inspection Report
Annual Inspection
Census: 33
Capacity: 40
Deficiencies: 4
Dec 10, 2007
Visit Reason
The inspection was an annual life safety code survey conducted to assess compliance with New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in several fire safety areas including fire clearance and inspections, fire alarms and smoke detectors, and staff and resident fire safety training. Specific issues included failure to maintain and inspect fire alarm systems, obstructed fire alarm pull stations, inadequate fire drills, and failure to ensure the range hood suppression system was inspected and maintained.
Deficiencies (4)
| Description |
|---|
| Failure to ensure the range hood suppression system and its components are inspected and maintained in accordance with NFPA 96. |
| Failure to ensure the fire alarm system and its components are maintained and inspected in accordance with NFPA 72 (1999 Edition). |
| Fire alarm pull station located at the front entry was obstructed by a chair, making it not easily accessible. |
| Failure to conduct fire drills at least quarterly on every shift, with no evidence of drills for the day shift between 4/30/07 and 10/18/07. |
Report Facts
Licensed capacity: 40
Census: 33
Number of shifts per day: 3
Fire drills frequency: 1
Fire drill spacing: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Sandoval | Executive Director | Signed the report and mentioned as responsible for monitoring fire alarm pull station compliance and fire drill completion |
| Maintenance Coordinator | Interviewed regarding fire safety deficiencies, responsible for scheduling repairs, monitoring rewiring of range hood, and conducting fire drills | |
| Administrator | Acknowledged findings at exit conferences | |
| Reminiscence Coordinator | Responsible for ensuring fire alarm pull station is unobstructed |
Inspection Report
Complaint Investigation
Deficiencies: 7
Dec 4, 2007
Visit Reason
The inspection was conducted to investigate complaints related to admissions, reporting of incidents, custodial drug permits, and related regulations and codes at Sunrise of Albuquerque.
Findings
The facility was found deficient in maintaining proper documentation for admission/retention exceptions, incident reporting, custodial drug permits, and employee criminal history screening and training. Multiple incidents were not reported to the state agency as required, and required training and documentation were missing or incomplete.
Complaint Details
The visit was complaint-related, focusing on allegations of failure to report medication errors and other incidents, failure to maintain proper documentation, and failure to comply with training and screening requirements. The community was unaware that medication errors were reportable incidents and failed to report them to the state agency. The complaint was substantiated by findings of missing documentation and failure to report incidents.
Deficiencies (7)
| Description |
|---|
| Failure to maintain documentation associated with the individual service plan as required for admission/retention exceptions. |
| Failure to ensure that incidents of resident abuse, neglect, exploitation, and mistreatment were reported to the Licensing Authority and Adult Protective Services as required. |
| Failure to maintain records of visits by the consultant pharmacist and ensure proper medication storage and labeling. |
| Failure to have documentation that direct care staff had been cleared through the New Mexico Caregivers' Criminal History Screening Program for 1 of 17 employee files reviewed. |
| Failure to ensure training on incident reporting, intake, processing, and training requirements was available and documented for 100% of staff. |
| Failure to ensure documentation of notification to family members or guardians regarding incident reporting information in 100% of sampled resident files. |
| Failure to ensure the division Incident Management Information poster was posted as required. |
Report Facts
Deficiencies cited: 7
Employee files reviewed: 17
Staff missing clearance: 1
Incident dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Sandoval | Executive Director | Named in relation to the admission/retention exceptions and acknowledged issues during interviews. |
| Care Coordinator | Interviewed regarding incident reporting and admission documentation; no full name provided. |
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