Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Jul 29, 2025
Visit Reason
The inspection was conducted as a complaint survey on 07/29/2025 to investigate state requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults.
Findings
The facility was found deficient for failing to ensure that one of two resident files contained a physical examination report completed within the past six months by a primary care physician. The complaint intake was investigated with no deficiencies cited.
Complaint Details
Complaint Intake NM was investigated with no deficiencies cited, but the complaint survey identified a deficiency related to resident records for physical examination documentation.
Deficiencies (1)
| Description |
|---|
| Failed to ensure for 1 of 2 residents that the physical examination report was completed within the past six months by a primary care physician. |
Report Facts
Resident Census: 83
Residents files reviewed: 2
Deficient resident files: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed during interview that the resident did not have an updated Healthcare Practitioner's statement in the file. | |
| Health and Wellness Director | Confirmed during interview that the resident did not have an updated Healthcare Practitioner's statement in the file and described corrective actions implemented. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Apr 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation survey completed on 04/03/2024 for state requirements of NMAC 7.8.2, Regulations for Assisted Livings for Adults, following two complaint intakes.
Findings
The facility was found deficient in protecting residents from financial abuse and misappropriation by staff, resulting in a resident experiencing financial and psychosocial harm due to a substantial loss of income. The facility has implemented a plan of correction including staff training and new employee orientation to prevent recurrence.
Complaint Details
Two complaint intakes were investigated; one was substantiated with deficiencies cited related to financial abuse and misappropriation, and the other was investigated with no deficiencies cited. The substantiated complaint involved a resident who was coerced into giving a $2000 loan to a staff member, with multiple interviews and documentation confirming the incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure residents were free from financial abuse and misappropriation by staff, resulting in harm to a resident. |
Report Facts
Resident Census: 78
Loan amount: 2000
Dates of training and orientation: 2/29/24 Wellness ANE training, 3/28/24 New Employee Orientation, 4/25/24 All staff training, 7/18/24 New Employee Orientation
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 2, 2021
Visit Reason
The inspection was conducted as an offsite complaint survey related to Complaint #NM47785 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the offsite complaint survey, and the complaint was found to be unsubstantiated.
Complaint Details
Complaint #NM47785 was unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Deficiencies: 0
Aug 19, 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 20, 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 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 offsite surveillance survey.
Inspection Report
Routine
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
Apr 8, 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
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
Jan 2, 2018
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: 76
Deficiencies: 6
Oct 13, 2017
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to assess compliance with state requirements for Assisted Living Facilities, including investigation of Complaint Intake NM#30365 which was unsubstantiated.
Findings
The facility was found deficient in multiple areas including staff training, admissions and discharge procedures, custodial drug permits and medication storage, maintenance of building and grounds, heating and ventilation system maintenance, and hospice care coordination. Specific deficiencies included inadequate supervised training for direct care staff, incomplete admission agreements, improper storage of oxygen tanks, unsafe sidewalk conditions, lack of annual maintenance for gas heating systems, and failure to hold hospice team meetings for residents receiving hospice care.
Complaint Details
Complaint Intake NM#30365 was unsubstantiated with no deficiencies cited related to the complaint.
Deficiencies (6)
| Description |
|---|
| Failed to ensure 2 of 4 Direct Care Staff received the required 16-hour supervised training prior to providing unsupervised care. |
| Admission agreements for 7 residents were missing required information including staffing ratio and termination conditions. |
| Failed to convene hospice team meetings prior to admitting or retaining 2 hospice residents. |
| Oxygen cylinder tanks were not secured and stored correctly in resident rooms, posing a safety hazard. |
| Sidewalks on facility property had several uneven concrete slabs creating tripping hazards. |
| Gas heating system and water heating system were not checked, tested, or maintained annually. |
Report Facts
Direct Care Staff supervised training deficiency: 2
Resident census: 76
Residents with incomplete admission agreements: 7
Hospice residents without team meeting: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Confirmed supervised training hours and hospice team meeting deficiencies. | |
| Administrator | Confirmed missing admission agreement information and lack of maintenance for heating systems. | |
| Guest Service Manager | Confirmed oxygen cylinder storage in resident rooms. | |
| Maintenance Director | Confirmed uneven concrete slabs on sidewalks. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2014
Visit Reason
A complaint investigation was completed for intake NM00029554 on 10/09/14 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 NM00029554 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2013
Visit Reason
A complaint investigation was completed for intake #28784 on 10/09/13 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint intake #28784 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 81
Capacity: 76
Deficiencies: 7
Feb 15, 2012
Visit Reason
An annual inspection was conducted to assess compliance with licensing requirements, including capacity limits, staff training, staffing ratios, resident rights, building construction, hazardous areas, and hospice care provisions.
Findings
The facility was cited for exceeding licensed capacity, inadequate staff training including hospice training, insufficient staffing ratios during sleeping hours, failure to provide humane care in a timely manner, residents housed in rooms not approved by the licensing authority, fire doors blocked open in hazardous areas, and failure to provide required hospice training and support to staff.
Deficiencies (7)
| Description |
|---|
| Facility exceeded licensed capacity with 81 residents present versus licensed capacity of 76. |
| Staff training requirements not met; one direct care staff (#103) lacked required annual training including hospice training. |
| Staffing ratios during resident sleeping hours were below minimum requirements; only two direct care staff on duty for 81 residents. |
| Failure to provide humane care for a resident needing toileting assistance; 26-minute delay in response to call for help. |
| 27 residents housed in rooms not approved by the licensing authority for assisted living. |
| Fire rated doors to hazardous laundry areas were blocked open, preventing self-closing devices from functioning. |
| Facility failed to provide required hospice training and psychological support for staff assisting hospice residents. |
Report Facts
Licensed capacity: 76
Current census: 81
Residents in unapproved rooms: 27
Direct care staff on sleeping shift: 2
Delay in toileting assistance: 26
Staff training hours required: 12
Hospice training hours required: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #103 | Direct Care Staff | Named in findings for lack of required annual training and hospice training. |
| Staff #104 | Staff Member | Interviewed regarding staffing levels and toileting assistance delay. |
| Administrator | Acknowledged census, room assignments, and fire door issues. | |
| Facility Nurse | Acknowledged census, staff training deficiencies, and hospice services. |
Inspection Report
Re-Inspection
Deficiencies: 2
Jan 22, 2009
Visit Reason
This inspection was a re-inspection visit conducted to verify correction of deficiencies cited in the previous November 18, 2008 survey.
Findings
The facility was found to have repeat deficiencies related to resident assessments and individual service plans, including missing elements in resident assessments and care plans, and inconsistent implementation of care plans. The facility acknowledged these deficiencies and submitted plans for correction including revised assessment forms and care plans, staff training, and monthly audits.
Deficiencies (2)
| Description |
|---|
| Resident assessment did not include required elements such as mood and behavioral patterns, disease diagnoses, health conditions, and skin conditions. |
| Resident care plans did not include all minimum requirements and were not consistently implemented, with missing documentation and lack of staff understanding on how to read care plans. |
Report Facts
Number of sampled residents with deficient assessments: 4
Number of sampled residents with deficient care plans: 7
Number of sampled residents with care plan implementation issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Manager | Corporate Health and Wellness Director and Community Health and Wellness Manager | Named in plan of correction for revising resident assessment and care plan forms and monitoring compliance |
| Staff #1 | Interviewed staff who stated lack of knowledge on how to read care plans |
Inspection Report
Original Licensing
Deficiencies: 5
Nov 24, 2008
Visit Reason
The inspection was conducted as an original licensing survey to assess compliance with New Mexico regulations for Adult Residential Care Facilities.
Findings
The facility was found deficient in several areas including resident assessments, individual service plans, medication administration, staff fire and safety training, and incident reporting. Corrective actions were planned and deficiencies were corrected upon notification.
Deficiencies (5)
| Description |
|---|
| Resident assessments did not include required elements such as mood and behavioral patterns, disease diagnoses, health conditions, and skin conditions. |
| Resident care plans failed to include all minimum requirements such as when and how often services will be provided, goals and outcomes, and documentation of facility's determination to meet resident needs. |
| Facility failed to have certificates showing staff assisting with medications had completed approved medication training for 15 of 16 staff members. |
| Facility failed to conduct fire drills emphasizing orderly evacuation and maintain records of evacuation times; residents were not evacuated during drills. |
| Facility failed to ensure 7 of 16 residents, family members, or guardians received notification regarding incident reporting. |
Report Facts
Staff members without medication training certificates: 15
Residents/family not notified of incident reporting: 7
Fire drills conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Acknowledged missing elements in resident assessments and care plans during interviews. |
| Health and Wellness Manager | Responsible for revising forms, monitoring medication certificates, auditing certificates monthly, and reviewing incident reporting forms. | |
| Administrator | Acknowledged missing medication certificate for staff member #6 and absence of documentation for incident reporting. | |
| General Manager | Will conduct monthly fire drills on all three shifts and maintain logs. | |
| Plant Operations Supervisor | Acknowledged fire drills did not include evacuation of residents. |
Inspection Report
Annual Inspection
Census: 74
Capacity: 76
Deficiencies: 6
Nov 20, 2008
Visit Reason
The inspection was conducted as an annual survey for the Life Safety Code portion of the New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure all required smoke detectors were approved, maintained, inspected, and tested according to regulations, and failed to provide required sensitivity testing for smoke detectors. Additionally, the facility did not assure that building elements attached to the building were equipped with a sprinkler system as required.
Deficiencies (6)
| Description |
|---|
| Smoke doors located between resident rooms 319 & 320 did not have a smoke detector located on either side of the smoke doors within five feet. |
| Smoke doors located between resident rooms 302 & 304 did not have a smoke detector located on either side of the smoke doors within five feet. |
| Smoke doors located between resident rooms 219 & 220 did not have a smoke detector located on either side of the smoke doors within five feet. |
| Smoke doors located between resident rooms 202 & 204 did not have a smoke detector located on either side of the smoke doors within five feet. |
| Facility failed to provide for testing of smoke detectors for sensitivity as required, with no evidence sensitivity testing was performed. |
| Building elements attached to the building, such as roofing and canopies extending more than 4 feet, were not equipped with a sprinkler system as required. |
Report Facts
Licensed capacity: 76
Census: 74
Inspection time frame: Inspection conducted between 8:30 am and 12:00 pm on November 20, 2008
Scheduled sensitivity testing date: Sensitivity testing scheduled for 3/10/2009
Expected sprinkler installation completion date: Expected installation and completion by 4/24/2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding smoke detector compliance and sprinkler system upgrades | |
| Director of Maintenance | Interviewed regarding fire alarm company notification for sensitivity testing |
Inspection Report
Annual Inspection
Census: 74
Capacity: 76
Deficiencies: 6
May 24, 2007
Visit Reason
Annual Life Safety Code survey conducted on 05/24/2007 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to maintain fire protection systems including smoke barriers and self-closing fire doors, lighting fixtures were not properly shaded or protected, exit doors were obstructed by draperies, exit stairwells were used for storage, fire inspections were not current, and sprinkler systems had obstructions affecting spray patterns. These deficiencies affected all staff and residents.
Deficiencies (6)
| Description |
|---|
| Fire protection systems including smoke barriers and self-closing fire doors were not maintained in safe and functioning condition; several fire doors did not close or latch properly on multiple floors. |
| Lighting fixtures were not shaded or protected from accidental breakage; unshielded light fixtures were found on all floors in various rooms. |
| Exit doors were obscured by draperies, which concealed exits and violated NFPA 101 requirements. |
| Exit stairwells were used for storage of employee lockers and clothes racks, obstructing egress paths. |
| Facility failed to have current annual fire inspection; last inspection was over a year prior to survey. |
| Sprinkler system spray patterns were obstructed by stored items within required clearance distances; clearance between sprinkler deflectors and storage was less than 18 inches in multiple areas. |
Report Facts
Licensed capacity: 76
Census: 74
Inspection date: May 24, 2007
Fire inspection date: Mar 14, 2006
Corrective action completion dates: Jun 7, 2007
Corrective action completion dates: Jun 9, 2007
Corrective action completion date: Jun 25, 2007
Corrective action completion date: Jun 18, 2007
Corrective action completion date: Jun 19, 2007
Corrective action completion dates: May 25, 2007
Corrective action completion date: Jun 21, 2007
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding fire door deficiencies, lighting, exit door draperies, stairwell storage, fire inspection, and sprinkler system issues. | |
| Plant Operations Supervisor | Interviewed and involved in corrective actions for fire door repairs, lighting shielding, exit door drapery removal, stairwell storage removal, fire inspection scheduling, and sprinkler system maintenance. | |
| Maintenance Staff | Responsible for ongoing monitoring and maintenance of fire doors, lighting, and sprinkler system. | |
| Guest Services Supervisor | Involved in housekeeping and laundry area corrections related to sprinkler clearance. | |
| Housekeeping Staff | Involved in housekeeping and laundry area corrections related to sprinkler clearance. | |
| Chef and Sous Chef | Involved in dietary kitchen and dry goods storage corrections related to sprinkler clearance. | |
| Beauty Shop Staff | Involved in clearing sprinkler obstructions in beauty shop closet. |
Inspection Report
Routine
Deficiencies: 16
May 23, 2007
Visit Reason
The inspection was a routine regulatory survey of the Acantilado Vista adult residential care facility to assess compliance with licensure and regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to timely submit application for change of administrator, failure to convene team meetings for residents requiring greater care, incomplete resident assessments and service plans, medication administration and documentation errors, improper food labeling, inadequate hot water temperature control, and incomplete fire drill documentation.
Deficiencies (16)
| Description |
|---|
| Failure to submit application for change of facility administrator within 10 working days of change. |
| Failure to convene a team to determine if a resident requiring greater care should remain in the facility. |
| Failure to review resident assessments every six months for 2 of 6 sampled residents. |
| Failure to include skilled nursing services in the individual service plan for a resident receiving such services. |
| Failure to review individual service plans at least every six months for 2 of 6 sampled residents. |
| Failure to maintain accurate medication receipt records for reconciliation. |
| Failure to notify physician or document medication error for a resident. |
| Failure to document dates when medication was discontinued or changed on the Medication Administration Record. |
| Failure to include name/signature of all staff administering medications on Medication Administration Record. |
| Failure to label and date perishable foods in the refrigerator. |
| Failure to maintain hot water temperature accessible to residents within 95 to 110 degrees Fahrenheit. |
| Failure to conduct monthly fire drills for 2 of the last 12 months. |
| Failure to record evacuation time in total minutes for 9 of 10 fire drills held in the past year. |
| Failure to apply for caregiver criminal history screening upon offer of employment for 1 of 4 sampled staff. |
| Failure to apply for caregiver criminal history screening within 20 calendar days from first day of employment for 2 of 4 sampled staff. |
| Failure to conduct Employee Abuse Registry inquiry prior to employment for 1 of 4 sampled staff. |
Report Facts
Months between resident assessment reviews: 10
Months between resident assessment reviews: 7
Months between individual service plan reviews: 7
Months between individual service plan reviews: 8
Temperature: 115.1
Temperature: 110.4
Fire drills missing: 2
Fire drills missing evacuation time: 9
Staff missing CCHS: 1
Staff missing CCHS within 20 days: 2
Staff missing EAR inquiry: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S11 | Staff member with missing caregiver criminal history screening upon rehire and missing Employee Abuse Registry inquiry prior to employment | |
| S12 | Staff member with delayed caregiver criminal history screening beyond 20 days of hire | |
| Administrator | Acknowledged failure to submit change of administrator application, failure to convene team meetings, and failure to apply for CCHS and EAR screenings | |
| Health and Wellness Director | Acknowledged multiple deficiencies including medication errors, resident assessment and service plan issues, and staff screening failures | |
| Maintenance Operations Supervisor | Acknowledged missing fire drills and missing evacuation time documentation | |
| Executive Chef | Acknowledged failure to label and date perishable foods |
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