Inspection Report
Original Licensing
Census: 4
Deficiencies: 10
Aug 18, 2021
Visit Reason
The inspection was an initial survey completed on 08/18/21 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, admission and discharge agreements, resident records, individual service plans, custodial drug permits, medication administration, housekeeping services, doors, and fire drills. Deficiencies could likely affect the safety and welfare of residents.
Deficiencies (10)
| Description |
|---|
| Administrator did not have a certificate of completion from a state approved training course for Assisted Living Administrators. |
| Direct Care Staff failed to have documentation of required supervised training and orientation. |
| Admission/Discharge Agreements did not include a refund upon death policy in compliance with Senate Bill (SB) 0335 - 2013. |
| Resident records were not organized utilizing a table of contents and did not include recent photographs. |
| Individual Service Plans (ISPs) lacked goals and expected outcomes for residents reviewed. |
| Custodial drug permits and medication administration practices did not meet state and federal requirements. |
| Housekeeping services failed to store cleaning supplies and hazardous chemicals securely. |
| Oxygen cylinder tanks were stored unsecured and not protected from accidental damage. |
| Doors in resident bedrooms and bathrooms required two motions to exit or were locked, impeding evacuation. |
| Fire drills were not conducted monthly as required. |
Report Facts
Residents on census: 4
Direct Care Staff training hours: 16
Orientation training hours: 12
Fire drill frequency: 1
Fire drill duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and confirmed lack of training certificates and documentation; involved in corrective actions. | |
| Manager | Responsible for auditing files monthly and ensuring compliance with training and storage requirements. | |
| Pharmacist | Conducted audits of medications and medication administration records. |
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