Deficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 4
Nov 15, 2023
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to investigate Complaint Intake #NM61492 and to assess compliance with state requirements for Assisted Living Facilities for Adults.
Findings
No deficiencies were cited related to the complaint investigation. However, deficiencies were found related to kitchen sanitation (uncovered trash cans), building maintenance (cracked window), missing window screens, and failure to conduct monthly fire drills. Corrective actions and plans of correction were documented for each deficiency.
Complaint Details
Complaint Intake #NM61492 was investigated with no deficiencies cited related to the complaint.
Deficiencies (4)
| Description |
|---|
| The kitchen trash can was not covered with a tight-fitting lid, risking food contamination. |
| The building was not maintained in good repair; a cracked window pane was observed in room #7. |
| Windows in rooms #2 and #5 were missing screens, exposing residents to potential insect or rodent intrusion. |
| Fire drills were not conducted monthly from January 2023 through October 2023, risking resident safety in case of fire. |
Report Facts
Resident census: 8
Number of trash cans without lids: 2
Fire drills missing: 10
Crack length: 6.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle DaCosta | Administrator | Named as Administrator who provided census and confirmed deficiencies during interviews. |
| Residential Director | Confirmed the cracked window in room #7, missing window screens, and lack of fire drills during interviews. | |
| Operations Manager | Involved in implementing weekly walk-throughs and maintenance documentation. |
Inspection Report
Routine
Deficiencies: 0
Aug 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 COVID-19 infection prevention and control survey.
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 COVID-19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Jun 23, 2020
Visit Reason
An offsite 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
Monitoring
Deficiencies: 0
Apr 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
Mar 31, 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
Mar 18, 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
Re-Inspection
Deficiencies: 0
Oct 18, 2019
Visit Reason
The visit was a revisit survey to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the revisit survey completed on 10/18/2019.
Inspection Report
Original Licensing
Deficiencies: 12
Jul 31, 2018
Visit Reason
Initial survey completed for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, admission agreements, resident records, resident evaluations, individual service plans, resident rights, medication administration, nutrition, housekeeping, maintenance, fire safety, and employee abuse registry compliance.
Severity Breakdown
Class B: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure 3 Direct Care Staff were cleared by the Employee Abuse Registry prior to hire, submitted applications and fingerprints within 20 days of hire, and maintained clearance letters on file. | — |
| Failed to ensure 6 Direct Care Staff received required orientation training including reporting abuse, emergency procedures, medication assistance, and ISP implementation. | — |
| Admission agreements for 3 residents did not include a refund provision in case of death that complies with state statutes for prorated refund. | — |
| Resident records for 3 residents lacked required personal and demographic information including family contacts, age, photograph, marital status, physician, dentist, social history, emergency contacts, language, medication list, and diet. | — |
| Resident evaluations for 3 residents were not completed within 15 days prior to admission, not reviewed or updated every 6 months, and lacked required information such as ADLs, cognitive abilities, communication, vision, physical functioning, psychosocial status, mood, activity interests, nutrition, oral status, medication use, and special treatments. | — |
| Individual Service Plans for 3 residents were not completed within 10 days of admission, not reviewed or updated every 6 months, lacked hospice care coordination, and did not include goals or expected outcomes. | — |
| Failed to ensure Fire Safety Equivalency System rating was completed and evacuation score of 'prompt' maintained; exit doors had deadbolt locks that were not readily operable from inside. | Class B |
| Medical gases (oxygen) were stored improperly in unsecured cylinders near combustibles in the garage. | — |
| Failed to ensure medications were administered only by trained staff; Direct Care Staff assisting with medication lacked required state-approved training and certificates; Medication Administration Records were incomplete and missing required information such as brand/generic names and start/end dates. | Class B |
| Paint cans were stored in the kitchen pantry with food, risking contamination. | — |
| Facility grounds were not maintained in a safe, sanitary, and presentable condition; dog feces and weeds were present in outdoor areas. | — |
| Exit doors were locked with deadbolts and handles that did not release locks from inside, risking resident safety in emergencies. | — |
Report Facts
Deficiencies cited: 12
Employee Abuse Registry clearance failures: 3
Direct Care Staff missing required training: 6
Residents with deficient admission agreements: 3
Residents with deficient records: 3
Residents with deficient evaluations: 3
Residents with deficient ISPs: 3
Residents with missing FSES ratings: 3
Paint cans stored improperly: 3
Dog feces observed: 3
Direct Care Staff without medication training: 5
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