Inspection Reports for Desert Peaks Assisted Living & Memory Care
5525 Cottonbloom Ct, Las Cruces, NM 88007, United States, NM, 88007
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Inspection Report
Follow-Up
Census: 44
Deficiencies: 1
Jul 17, 2025
Visit Reason
The inspection visit was an offsite revisit/follow-up survey to verify correction of previously cited deficiencies related to medication administration in an assisted living facility.
Findings
The facility failed to initial the Medication Administration Record (MAR) for two residents to demonstrate if medications were missed, refused, or administered, representing an uncorrected deficiency from a prior survey. The administrator confirmed the MARs lacked initials and exceptions for medication administration on multiple dates.
Deficiencies (1)
| Description |
|---|
| Failure to initial the Medication Administration Record (MAR) for 2 residents to demonstrate if medication was missed, refused, or administered. |
Report Facts
Resident census: 44
Number of residents with MAR deficiencies: 2
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
May 21, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to medication administration at Desert Peaks Assisted Living and Memory Care.
Findings
The facility was found deficient in medication administration practices, specifically failing to ensure that the Medication Administration Record (MAR) was properly initialed to document if medications were missed, refused, or administered for one resident. This could lead to incomplete resident records and potential medication errors.
Complaint Details
Complaint Intake NM was investigated with deficiencies cited related to medication administration.
Deficiencies (1)
| Description |
|---|
| Failed to ensure for 1 resident that the Medication Administration Record (MAR) was initialed to demonstrate if the medication was missed, refused, or administered. |
Report Facts
Resident Census: 36
Resident Census: 11
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Coordinator | Confirmed that the MAR did not contain initials of the person assisting with medication administration for resident #3 | |
| Wellness Director | Responsible for auditing medication passes and ensuring compliance as part of the plan of correction | |
| Administrator | Oversight of medication administration compliance and plan of correction | |
| Regional Director | Oversight of medication administration compliance and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 22, 2024
Visit Reason
The inspection was conducted as a Complaint Survey on 10/22/24 to investigate multiple complaints related to staff training, incident reporting, and resident safety at Desert Peaks Assisted Living and Memory CA.
Findings
The facility was found deficient in ensuring staff received required orientation and annual training, proper documentation of training was missing for multiple staff members, and incident reporting and follow-up procedures were inadequate. Several resident incidents including elopements and falls were not properly documented or reported to the Licensing Authority.
Complaint Details
The complaint investigation involved multiple complaints (redacted complaint numbers) regarding staff training deficiencies and incident reporting failures. The findings substantiated that staff training documentation was incomplete and incident reports for resident elopements and falls were not properly handled or reported to the Licensing Authority.
Deficiencies (2)
| Description |
|---|
| Failure to ensure staff records for orientation and annual training were complete and documented for multiple direct care staff and medication technicians. |
| Failure to report and investigate incidents of resident abuse, neglect, exploitation, and injuries in accordance with state regulations. |
Report Facts
Hours of orientation training required: 16
Hours of annual training required: 12
Number of residents potentially harmed: 36
Number of staff with missing training documentation: 17
Number of incidents reviewed for compliance: 6
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 6
Dec 23, 2021
Visit Reason
Complaint survey conducted on 12/23/21 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities, including multiple complaints with some substantiated and others unsubstantiated.
Findings
The facility failed to ensure direct care staff received clearances from the Employee Abuse Registry prior to hire and timely submission of fingerprints for the Caregivers Criminal History Screening Program. Staff training requirements were not met, including supervised training and annual orientation. Admission/discharge agreements lacked a required refund upon death policy. Individual Service Plans were not updated timely. Several incidents of possible abuse, neglect, or exploitation were not reported to the Licensing Authority within required timeframes. Staff were observed not wearing required N95 or K95 masks during positive COVID-19 cases.
Complaint Details
Multiple complaints were investigated with some substantiated and others unsubstantiated. Deficiencies were cited related to employee abuse registry clearances, staff training, admission agreements, incident reporting, and infection control.
Deficiencies (6)
| Description |
|---|
| Direct Care Staff did not receive clearances from the Employee Abuse Registry prior to hire and fingerprint submissions were not timely. |
| Direct Care Staff did not receive 16 hours of supervised training prior to unsupervised care and 12 hours of required orientation and annual training. |
| Admission and Discharge Agreements did not include a Refund upon Death policy compliant with Senate Bill 0335-2013. |
| Individual Service Plans were not updated at least every 6 months as required. |
| Incidents of possible abuse, neglect, or exploitation were not reported to the Licensing Authority within 24 hours or next business day for multiple residents. |
| Staff were not wearing N95 or K95 masks at all times inside the facility during positive COVID-19 cases. |
Report Facts
Residents affected: 36
Deficiencies cited: 6
Direct Care Staff without EAR clearance prior to hire: 4
Residents without Refund Upon Death policy in admission agreement: 10
Residents with unreported incidents: 4
Residents census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #1 | Administrator | Confirmed lack of Employee Abuse Registry clearances prior to hire and lack of staff training documentation; confirmed incidents were not reported to Licensing Authority; confirmed staff not wearing N95 masks. |
Inspection Report
Follow-Up
Deficiencies: 2
Dec 23, 2021
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, specifically related to hospice and memory care unit regulations.
Findings
The facility was found deficient in ensuring that Direct Care Staff (DCS) completed the required annual training: 6 hours of palliative/hospice care training and 12 hours of Alzheimer's/dementia care training. These deficiencies were uncorrected from prior surveys and posed a risk of harm to residents receiving hospice and memory care services.
Deficiencies (2)
| Description |
|---|
| Failed to ensure Direct Care Staff completed a minimum of six (6) hours per year of palliative/hospice care training. |
| Failed to ensure Direct Care Staff completed the required twelve (12) hours of Alzheimer's/dementia care training annually. |
Report Facts
Residents receiving hospice care: 9
Residents receiving Alzheimer's/dementia care: 18
Hours of required palliative/hospice training: 6
Hours of required Alzheimer's/dementia training: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #3 | Direct Care Staff | No documentation of required hospice and Alzheimer's/dementia training. |
| DCS #4 | Direct Care Staff | No documentation of required hospice and Alzheimer's/dementia training. |
| DCS #8 | Direct Care Staff | No documentation of required hospice and Alzheimer's/dementia training. |
| DCS #13 | Direct Care Staff | No documentation of required hospice and Alzheimer's/dementia training. |
| Interim Administrator Raymond Craig | Interim Administrator | Confirmed lack of documentation for required training for DCS #3, #4, #8, and #13. |
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 2
Dec 1, 2020
Visit Reason
The document is a Plan of Correction submitted in response to an offsite complaint survey completed on 11/30/2020 for Desert Peaks Assisted Living and Memory Care, facility 2266.
Findings
The survey found deficiencies related to facility reports, records, rules, policies, and procedures, specifically regarding employee files, documentation of disciplinary actions, and incident reporting. The Plan of Correction outlines actions taken to address these deficiencies, including review and filing of staff records and implementation of a new payroll system.
Complaint Details
Complaint #NM43685 was unsubstantiated with deficiencies cited.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure employee files including documentation of disciplinary actions and reasons for involuntary terminations were maintained onsite and available for review. |
| Facility failed to report an incident of alleged exploitation and misappropriation of resident monies/credit cards to the Licensing Authority within 24 hours or the next business day. |
Report Facts
Resident census at risk: 29
Dates of employee termination: 1
Dates of staff meetings: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Woelke | Administrator | Named in relation to findings about employee file documentation and disciplinary actions. |
| FDCS #1 | Former Direct Care Staff | Involved in alleged exploitation/misuse of resident funds and termination documentation deficiencies. |
| Business Service Director | Responsible for reviewing employee files on anniversary date and within 2 weeks of termination to verify document scanning. | |
| Wellness Director | Conducts incident investigations with the Administrator and submits reports to Licensing Authority. |
Inspection Report
Follow-Up
Deficiencies: 2
Sep 24, 2020
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, specifically related to hospice and memory care units.
Findings
The facility failed to ensure that Direct Care Staff (DCS) received the required annual training: six hours of palliative/hospice care training including one hour specific to the resident's Individual Service Plan (ISP), and twelve hours of Alzheimer's/Dementia training annually. This deficiency was uncorrected from a prior survey dated 12/18/19 and posed a risk of harm to residents receiving hospice and memory care services.
Deficiencies (2)
| Description |
|---|
| Failed to ensure Direct Care Staff received the required six hours of palliative/hospice care training annually including one hour specific to the resident's Individual Service Plan. |
| Failed to ensure Direct Care Staff completed the required twelve hours of Alzheimer's/Dementia training annually. |
Report Facts
Hours of palliative/hospice training required: 6
Hours of Alzheimer's/Dementia training required: 12
Number of residents identified receiving hospice services: 3
Number of residents identified receiving Alzheimer's/dementia care services: 3
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 12
Dec 18, 2019
Visit Reason
The inspection was a Full-Onsite/Complaint survey completed on 12/18/19 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities. The visit was complaint-related with substantiated complaints NM00038343 and NM00038346.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, admissions and discharge procedures, reporting of incidents, custodial drug permits, nutrition, hazardous areas, fire safety, hospice care, and memory care units. Several repeat deficiencies from a prior survey dated 01/08/16 were noted. The facility failed to ensure timely clearance from the Employee Abuse Registry, adequate staff training, proper documentation of admissions and discharges, incident reporting, medication management, fire drills, and hospice care training.
Complaint Details
Complaint Intake NM00038343 and NM00038346 were substantiated with deficiencies cited. The facility failed to submit investigation/follow-up reports within required timeframes for incidents involving residents. Several incidents were not reported or investigated timely, placing residents at risk.
Deficiencies (12)
| Description |
|---|
| Staff qualifications not met; Employee Abuse Registry clearance not obtained prior to hire for multiple staff. |
| Direct Care Staff failed to receive all required annual trainings including fire safety, first aid, infection control, resident rights, and individual service plan implementation. |
| Admission and discharge agreements lacked required elements including refund policy, notification of rights, and termination conditions. |
| Incident reports for suspected abuse, neglect, or exploitation were not properly submitted or investigated within required timeframes. |
| Custodial drug permits and medication management procedures were deficient; medications not inventoried or stored properly. |
| Nutrition policies and menus did not meet requirements; special diets and meal cycles not properly managed. |
| Hazardous areas such as fuel fired equipment rooms and water heater rooms had penetrations and holes not properly sealed. |
| Fire extinguishers were not inspected or serviced as required; missing sprinkler heads and fire safety equipment deficiencies noted. |
| Fire drills were not conducted monthly as required; documentation incomplete. |
| Hospice care staff did not receive required palliative/hospice training; care coordination and documentation deficient. |
| Memory care unit staff did not receive required dementia and Alzheimer's disease training; care plans and service plans incomplete. |
| Exit doors in memory care unit were locked and not readily openable from inside; safety hazard for residents. |
Report Facts
Residents on census: 34
Repeat deficiencies: 2
Hours of required training: 16
Hours of annual training: 12
Hours of hospice training: 6
Fine amount: 5000
Fire extinguishers required: 2
Fire drills frequency: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 1, 2013
Visit Reason
Complaint investigations were completed for intakes NM00028527, NM00028851, NM00028992, and NM00028964 on 04/01/13 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
Complaints NM00028527 and NM00028851 were unsubstantiated with no deficiencies cited. Complaints NM00028964 and NM00028992 were substantiated with deficiencies cited related to resident rights and medication administration, including failure to follow physician's orders and documentation issues.
Complaint Details
Complaint investigations for intakes NM00028527, NM00028851 were unsubstantiated with no deficiencies. Complaints NM00028964 and NM00028992 were substantiated with deficiencies cited.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents are free from physical and emotional abuse, neglect, and misappropriation/exploitation as evidenced by not following current physician's orders for medication administration for sampled residents. |
| Failure to follow current physician's orders for medication administration, including documentation and clarification of orders, potentially causing harm to residents. |
Report Facts
Complaint intakes investigated: 4
Resident #s reviewed for medication issues: 3
Date of survey completion: Apr 1, 2013
Inspection Report
Original Licensing
Deficiencies: 2
Jul 22, 2009
Visit Reason
The inspection was conducted as an original licensing survey for Cottonbloom Assisted Living Community to assess compliance with state regulations regarding custodial drug permits and medication management.
Findings
The facility was found deficient in maintaining medications in a secure place for residents self-administering medications, specifically insulin stored in an unlocked refrigerator accessible to residents, staff, and visitors. Additionally, the facility failed to ensure insulin was administered immediately after removal from the pharmacy container for a diabetic resident.
Deficiencies (2)
| Description |
|---|
| Failure to have medications in a secure place in a resident's room, with insulin stored in an unlocked refrigerator accessible to residents, staff, and visitors. |
| Failure to ensure insulin was administered immediately after removal from the pharmacy container for a diabetic resident. |
Report Facts
Pre-filled syringes: 39
Units of insulin: 12
Units of insulin: 30
Units of insulin: 10
Units of insulin: 10
Units of insulin: 40
Units of insulin: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff S57 | Acknowledged resident keeps insulin in refrigerator and acknowledged Home Health Agency pre-fills syringes for resident R5. |
Inspection Report
Annual Inspection
Census: 68
Capacity: 88
Deficiencies: 3
Jul 20, 2009
Visit Reason
The inspection was an annual survey conducted to assess compliance with 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 building and grounds, specifically the failure of smoke doors to latch properly and failure to ensure fire alarm systems and strobes were inspected, maintained, and synchronized according to NFPA standards. These deficiencies potentially affected all residents and staff throughout the facility.
Deficiencies (3)
| Description |
|---|
| The double leaf smoke doors located to the Southeast and Southwest wings failed to latch when released from their magnetic hold open device. |
| The facility failed to ensure the fire alarm system and its components were inspected and maintained in accordance with NFPA 72, including sensitivity testing of smoke detection devices. |
| The fire alarm strobes throughout the building were not synchronized to flash together as required by NFPA 72 and NFPA 70. |
Report Facts
Licensed capacity: 88
Census: 68
Licensed capacity: 45
Census: 45
Inspection Report
Life Safety
Census: 43
Capacity: 45
Deficiencies: 4
Nov 7, 2008
Visit Reason
The visit was a revisit conducted on November 7, 2008, for the annual life safety code survey originally conducted on June 10, 2008, to assess compliance with the New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found to have repeat deficiencies related to maintenance of building and grounds, fire alarms, smoke detectors, and automatic fire protection sprinkler systems. Specific issues included doors being held open improperly, lack of heat detectors in the kitchen, and canopies not protected by sprinkler systems.
Deficiencies (4)
| Description |
|---|
| Failure to ensure all fire protection systems including smoke barriers and doors and shutters in smoke barriers are self-closing or automatic closing and maintained in safe and functioning condition. |
| Failure to ensure the fire alarm system and its components (including heat detectors) are installed, tested, and maintained in accordance with NFPA 72. |
| Failure to assure that heat detectors are installed in all enclosed kitchens and powered by the house electrical service. |
| Failure to assure that the three building elements attached to the building are equipped with a sprinkler system as required by the Life Safety Code and NFPA 13. |
Report Facts
Licensed capacity: 45
Census: 43
Survey date: Nov 7, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edgar Otte | Administrator | Signed the report and mentioned as the administrator |
| Assistant Administrator | Acknowledged findings related to doors held open, heat detector absence, and sprinkler system deficiencies |
Inspection Report
Original Licensing
Deficiencies: 2
Sep 3, 2008
Visit Reason
The inspection was conducted as an original licensing survey for Cottonbloom Assisted Living Community to assess compliance with state regulations related to caregiver criminal history screening requirements.
Findings
The facility failed to meet requirements for caregiver criminal history screening, including timely submission of applications, fingerprint cards, and inquiries to the Employee Abuse Registry for several employees. This was a repeat deficiency from a prior survey dated 6/4/08.
Deficiencies (2)
| Description |
|---|
| Failure to submit application, personal identification, release of information, fingerprint cards, or fees to the Caregiver Criminal History Screening (CCHS) for seven employees. |
| Failure to make inquiry to the Employee Abuse Registry prior to employing or contracting with six staff members. |
Report Facts
Employees with unmet CCHS requirements: 7
Staff without Employee Abuse Registry inquiry: 6
Inspection Report
Annual Inspection
Census: 34
Capacity: 45
Deficiencies: 6
Jun 10, 2008
Visit Reason
An annual life safety code survey was conducted on June 10, 2008, to assess compliance with New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to maintain fire protection systems including smoke barriers and doors, had doors held open by rubber wedges, lacked proper fire alarm and heat detection systems, and had canopies not protected by sprinkler systems. These deficiencies potentially affected all residents, staff, and visitors.
Deficiencies (6)
| Description |
|---|
| Failure to ensure all fire protection systems including smoke barriers and doors and shutters in smoke barriers are self-closing or automatic closing. |
| Doors leading from Dietary Kitchen to Dining Room, Dietary corridor to Dishwasher room, and Beauty shop to resident corridor were held open by rubber wedges. |
| Failure to ensure fire alarm system and components (including heat detectors) are installed, tested, and maintained in accordance with NFPA 72. |
| Heat detectors were not present in the kitchen as required. |
| Failure to assure that building elements attached to the building are equipped with a sprinkler system as required by NFPA 13 or NFPA 13D. |
| Canopies at the south west side exit, main entrance, and north west exit were not protected by sprinkler systems. |
Report Facts
Licensed capacity: 45
Census: 34
Survey date: Jun 10, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Surveyor 25921 | Life Safety Code Surveyor | Conducted the inspection and cited deficiencies |
| Administrator | Acknowledged findings and participated in facility tour | |
| Maintenance Supervisor | Acknowledged findings and participated in facility tour | |
| Maintenance Person | Acknowledged findings |
Inspection Report
Original Licensing
Deficiencies: 4
Jun 4, 2008
Visit Reason
The inspection was conducted as an original licensing survey for Cottonbloom Assisted Living Community to assess compliance with regulatory requirements.
Findings
The facility was found deficient in several areas including failure to have individual service plans reviewed by a licensed nurse every six months, inadequate screening of outside air ventilation openings for insects, and incomplete caregiver criminal history screening documentation for employees.
Deficiencies (4)
| Description |
|---|
| Failure to have the individual service plan (ISP) reviewed by a licensed nurse at least every 6 months for 4 residents. |
| Outside air used for ventilation was not screened for the control of insects; multiple resident rooms and staff time clock room had missing or torn window screens. |
| Failure to submit required Caregiver Criminal History Screening (CCHS) documentation and fees for certain employees within required timeframes. |
| Failure to inquire with the Employee Abuse Registry prior to employing individuals and maintain documentation of such inquiries for employees hired after the effective date of the rule. |
Report Facts
Residents with ISP deficiencies: 4
Employees missing CCHS documentation: 4
Employees lacking Employee Abuse Registry inquiry: 5
Inspection Report
Routine
Deficiencies: 1
Oct 4, 2007
Visit Reason
The inspection was conducted to assess compliance with medication administration regulations and to identify any deficiencies related to medication errors and proper medication management in the assisted living facility.
Findings
The facility failed to ensure that residents received medications as ordered by physicians for 9 sampled residents. Multiple medication errors were documented, including wrong medications given, missed doses, incorrect dosages, and documentation errors. The facility had policies for medication administration but did not consistently follow them, resulting in medication errors.
Deficiencies (1)
| Description |
|---|
| Failed to assure residents were receiving medications as ordered by the physician for 9 of 9 sampled residents. |
Report Facts
Sampled residents with medication errors: 9
Medication doses missed or given incorrectly: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Interviewed regarding actions taken after medication errors; described follow-up procedures including monthly med pass observation and incident reports with verbal warnings |
Inspection Report
Life Safety
Census: 32
Capacity: 45
Deficiencies: 6
Jul 6, 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 failed to ensure that fire protection systems, including smoke barriers and doors, were self-closing or automatic closing and maintained in safe and functioning condition. Additional deficiencies included blocked exit access, improper maintenance of electrical equipment clearance, unstable flooring, and failure to conduct required fire drills quarterly on all shifts.
Deficiencies (6)
| Description |
|---|
| Failure to ensure all fire protection systems including smoke barriers and doors are self-closing or automatic closing and maintained in safe and functioning condition. |
| Exit access and exit doors were obstructed, including a piano and table reducing egress path by 45 inches. |
| Electrical equipment room had boxes stored in front of electrical panels violating clearance requirements. |
| Floors in the Dietary Kitchen were cracking and peeling, creating slip and tripping hazards. |
| Sprinkler system spray pattern was obstructed by stored items and clearance between sprinkler head deflector and storage was less than required 18 inches. |
| Facility failed to conduct fire drills at least quarterly on every shift; fire drills were missing for several months and documentation was incomplete. |
Report Facts
Licensed capacity: 45
Census: 32
Egress path obstruction: 45
Vertical clearance: 6
Vertical clearance: 18
Fire drill frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey M Hailey | Administrator | Signed the report and acknowledged findings related to floor condition and fire drill scheduling. |
| Maintenance Person | Interviewed regarding fire protection systems, electrical wiring, and fire drill scheduling; acknowledged multiple findings. |
Inspection Report
Routine
Deficiencies: 5
Jul 28, 2005
Visit Reason
The inspection was a routine survey conducted to assess compliance with housekeeping, maintenance, comprehensive care plans, accident prevention, pharmacy services, and clinical record requirements.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance with various repairs needed, failure to follow care plans for wound care, inadequate supervision leading to safety hazards, expired medications and supplies in medication rooms, and incomplete clinical records for at least one resident.
Severity Breakdown
SS=E: 3
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain all areas in good repair including chipped paint, broken linoleum, gouged walls, torn wallpaper, and missing floor tiles. | SS=E |
| Facility failed to follow the care plan for wound care and monitoring for cancerous lesions for one resident. | SS=D |
| Facility failed to ensure adequate supervision and assistance devices to prevent accidents; therapy room containing hot water hydrocollator was left unlocked and unattended. | SS=E |
| Facility failed to ensure expired medications and supplies were removed from medication rooms and treatment carts. | SS=E |
| Facility failed to maintain complete clinical records; one resident's record lacked a history and physical. | SS=D |
Report Facts
Deficiencies cited: 5
Temperature: 160
Expired hemocult cards: 12
Expired yellow top vacu-tainer tubes: 22
Expired Prep Solution bottles: 2
Expired Sterile 0.9% Sodium Chloride bottles: 6
Expired hemocult cards: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed about lack of cushions and care plan adherence for resident wound care. |
| Director of Nurses | Director of Nursing (DON) | Interviewed regarding wound care monitoring, expired medications, and care plan adherence. |
| Physical Therapy Supervisor | Physical Therapy Supervisor | Interviewed about unlocked therapy room and Hydrocollator safety. |
| PT Aide | Physical Therapy Aide | Interviewed about locking procedures for therapy gym and Hydrocollator safety. |
| Medical Record Supervisor | Medical Record Supervisor | Interviewed regarding missing history and physical in resident medical record. |
Inspection Report
Routine
Deficiencies: 10
Mar 29, 2005
Visit Reason
The inspection was a routine survey of the Cottonbloom Adult Care facility to assess compliance with state regulations regarding housekeeping, building construction, maintenance, fire safety, ventilation, exits, and bathing facilities.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean environment; lack of submission of building alteration plans; accessibility issues for persons with disabilities; maintenance problems such as binding doors and dirty sprinkler heads; inadequate ventilation; non-functioning exit sign battery backups; improper grab bar installation; and lack of current fire inspection documentation.
Deficiencies (10)
| Description |
|---|
| Facility failed to maintain safe, clean, and presentable environment; exhaust and heater vent grills in smoking room were dirty. |
| Facility did not submit plans and specifications for alterations to the Alzheimer unit to Licensing Authority prior to construction. |
| Facility altered rooms in Alzheimer unit without proper approvals and structural support documentation. |
| Exit door threshold in Alzheimer unit was 1-3/8 inch high, not accessible for persons with disabilities. |
| Double leaf doors in corridor binding on top latch side; multiple doors binding on carpet or not latching properly. |
| Sprinkler heads in kitchen dishwashing room covered with grease and lint. |
| Storage room next to laundry used for cleaning supplies with strong odor and no mechanical exhaust vent. |
| Exit signs by resident room #124 and kitchen lacked functioning battery backup. |
| Whirlpool tub grab bars installed at an angle, not horizontal as required. |
| Facility lacked current annual fire inspection report; last report dated May 5, 2003. |
Report Facts
Date of inspection: Mar 29, 2005
Fire inspection report date: May 5, 2003
Exit sign battery test interval: 30
Exit sign annual test duration: 90
Grab bar mounting height: 33
Grab bar mounting height max: 36
Grab bar force tolerance: 250
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