Inspection Report Summary
The most recent inspection on November 21, 2024, found deficiencies related to the review and revision of resident evaluations and Individual Service Plans by qualified nursing staff, as well as failure to submit a required follow-up report after an unwitnessed fall. Earlier inspections showed a mixed pattern, with prior deficiencies involving medication availability, oxygen tank storage, documentation issues, safety hazards, and a substantiated complaint related to resident abuse and neglect in 2014. Complaint investigations were mostly unsubstantiated except for the 2014 case involving mistreatment and failure to report incidents timely. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports. The facility’s recent deficiencies reflect ongoing challenges with documentation and procedural compliance, while earlier serious issues appear to have been addressed.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
10 residents
Based on a November 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to compliance with state regulations for Assisted Living Facilities for Adults.
Complaint Details
The complaint investigation revealed deficiencies related to resident evaluations and ISPs not being reviewed or revised by qualified nursing staff, and failure to submit a timely follow-up report after an incident involving an unwitnessed fall. The Administrator confirmed these deficiencies during interviews.
Findings
The facility failed to ensure resident evaluations and Individual Service Plans (ISPs) were reviewed and revised by a licensed practical nurse, registered nurse, or physician extender. Additionally, the facility did not conduct and submit a required 5-day follow-up investigation report to the licensing authority after an incident involving an unwitnessed fall.
Deficiencies (3)
Failure to ensure resident evaluations were reviewed and revised by a licensed practical nurse, registered nurse, or physician extender.
Failure to ensure Individual Service Plans (ISPs) were reviewed and revised by a licensed practical nurse, registered nurse, or physician extender.
Failure to conduct and submit a 5-day follow-up investigation report to the licensing authority after an incident.
Report Facts
Date of survey completion: Nov 21, 2024
Incident investigation timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and confirmed facility was not contracted with a nurse to review evaluations and ISPs, and confirmed failure to submit 5-day follow-up report |
Inspection Report
Re-Inspection
Census: 10
Deficiencies: 2
Date: Nov 13, 2023
Visit Reason
The visit was a Revisit survey conducted to assess compliance with state requirements for Assisted Living Facilities for Adults, specifically addressing previously cited deficiencies.
Findings
The facility failed to ensure resident prescribed medications were available as ordered and oxygen cylinder tanks were stored securely and protected from accidental damage. Four unsecured oxygen tanks were found stored in a cardboard box next to combustible materials, and a prescribed PRN medication for a resident was not available as ordered.
Deficiencies (2)
Failure to ensure resident prescribed medications were available to take as ordered.
Oxygen cylinder tanks were not stored securely and were placed next to combustible materials, risking accidental damage and fire hazard.
Report Facts
Census: 10
Oxygen cylinder tanks: 4
Inspection Report
Routine
Deficiencies: 0
Date: Apr 16, 2020
Visit Reason
An offsite surveillance survey was conducted related to Covid-19 infection, prevention and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Date: 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
Date: Mar 16, 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
Date: Nov 9, 2017
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.
Findings
No deficiencies were cited during the Revisit/Follow-up survey. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 6
Date: Sep 7, 2017
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted on 09/07/2017 to assess compliance with state regulations for Assisted Living Facilities, including investigation of Complaint Intake NM#30304 which was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint Intake NM#30304 was investigated and found unsubstantiated with no deficiencies cited.
Findings
The facility was found deficient in multiple areas including medication administration records missing required information for two residents, lack of documentation for refrigerator/freezer and dishwasher temperature logs, inadequate ventilation in the linen closet, unsafe conditions in the backyard patio posing tripping hazards, lack of annual inspection documentation for the gas heating system, and non-functional emergency lighting.
Deficiencies (6)
Medication Administration Records (MARs) for 2 residents did not include physician's name/contact information or both brand/generic medication names.
Facility failed to maintain daily logs of refrigerator/freezer temperatures and monthly logs for dishwasher temperatures.
Linen closet used for resident towels and sheets lacked ventilation.
Backyard cement patio had large cracks and chips creating tripping hazards.
No documentation of annual inspection, testing, and maintenance of the gas heating system.
Emergency lights in the facility did not work or turn on when tested.
Report Facts
Residents on census: 9
Medication Administration Records reviewed: 4
Residents with MAR deficiencies: 2
Emergency lights not working: 6
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 13, 2014
Visit Reason
A complaint investigation was completed for intake NM00029336 on 02/13/14 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living. The complaint was substantiated with deficiencies cited.
Complaint Details
The complaint was substantiated with deficiencies cited related to abuse and neglect by Caregiver #1 involving multiple residents. The facility failed to report these incidents timely to the licensing authority. Interviews with administrators, house managers, employees, residents, and family members confirmed the abuse and neglect. The caregiver was described as rough, loud, disrespectful, and neglectful. The facility's reporting policies require immediate reporting, which was not followed.
Findings
The facility failed to report incidents of resident abuse and neglect to the Licensing authority within a twenty-four (24) hour period, resulting in mistreatment of 6 cognitively impaired residents who required assistance for all Activities of Daily Living. Deficiencies included rough handling, pulling residents by their arms, leaving residents unattended in bathrooms, verbal belittling, yelling, and disrespectful behavior by a caregiver. Staff and family interviews confirmed these behaviors and failure to report incidents timely.
Deficiencies (2)
Failure to report incidents of resident abuse and neglect to the Licensing authority within a twenty-four (24) hour period.
Resident abuse including rough handling, pulling residents by arms during transfers, leaving residents unattended in bathrooms, verbal belittling, yelling, and disrespectful behavior by Caregiver #1.
Report Facts
Number of residents affected: 6
Days delay in reporting: 12
Days delay in reporting: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #1 | Named as the caregiver responsible for abuse and neglect incidents involving multiple residents. | |
| Employee #1 | Witnessed abuse incidents and reported concerns to management on January 7th. | |
| House Manager #1 | Received delayed reports of abuse incidents and provided interviews regarding the events. | |
| House Manager #2 | Received delayed reports of abuse incidents and provided interviews regarding the events. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2013
Visit Reason
A complaint investigation was completed for intake NM00029009 on 06/11/13 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Complaint Details
Complaint intake NM00029009 was investigated and found unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 2, 2013
Visit Reason
An initial survey was completed for NMAC 7.8.2 regulations governing Assisted Living facilities.
Findings
No deficiencies were cited during the initial survey.
Inspection Report
Original Licensing
Capacity: 10
Deficiencies: 0
Date: Oct 3, 2012
Visit Reason
An initial Life Safety Code survey was conducted at the facility per the provider's request.
Findings
The facility was found to be in substantial compliance with the Life Safety Code portion of the New Mexico State Requirements for Assisted Living Facilities for Adults 7 NMAC 8.2. Temporary licensure is recommended for 10 residents.
Report Facts
Temporary licensure capacity: 10
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