Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 11, 2024
Visit Reason
The inspection was conducted as a complaint survey to investigate a complaint intake regarding the facility's compliance with state regulations for assisted living for adults.
Findings
The facility was found deficient in compliance with NMAC 8.370.14.34 regarding custodial drug permits and medication storage, as well as failure to ensure proper storage and signage for oxygen tanks and unsecured cleaning supplies, which could potentially affect resident safety and welfare.
Complaint Details
Complaint intake was investigated and deficiencies were not cited related to the complaint intake itself, but deficiencies were cited related to medication storage and safety practices.
Deficiencies (3)
| Description |
|---|
| Failure to meet requirements for custodial drug permits including proper procurement, labeling, storage, and destruction of medications. |
| Failure to ensure oxygen cylinder tanks were stored in a secure location and proper signage indicating oxygen use was missing. |
| Failure to ensure cleaning supplies and hazardous chemicals were stored in secured areas inaccessible to residents. |
Report Facts
Date of survey completion: Dec 11, 2024
Date of complaint investigation: Dec 9, 2024
Number of unsecured oxygen tanks observed: 2
Number of unsecured cleaning chemicals observed: 8
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 7
Sep 30, 2022
Visit Reason
The inspection was a Full-Onsite/Complaint survey completed on 09/30/22 for the state requirements of NMAC 7.8.2, Regulations for Assisted Living Facilities for Adults. The complaint intake NM #48685 was unsubstantiated with no deficiencies cited.
Findings
The facility was found deficient in multiple areas including incomplete documentation of Direct Care Staff training, failure to update resident evaluations and Individual Service Plans at required intervals, and inadequate fire safety practices including incomplete fire drill documentation and lack of fire safety training for staff and residents. These deficiencies could place residents at risk of harm.
Complaint Details
Complaint Intake NM #48685 was unsubstantiated with no deficiencies cited.
Deficiencies (7)
| Description |
|---|
| Failed to ensure Direct Care Staff training files included complete documentation of 16 hours supervised training prior to unsupervised care and 12 hours of orientation training with proof of competency. |
| Failed to ensure resident evaluations were reviewed and updated at least every 6 months for 2 of 4 residents reviewed. |
| Failed to develop and implement Individual Service Plans within 10 calendar days of admission and review/revise them at least every 6 months for 2 of 4 residents reviewed. |
| Failed to conduct monthly fire drills on each 8-hour shift per quarter with required documentation including number of residents participating and problems noted. |
| Failed to ensure staff were trained on fire safety procedures including use of fire extinguishers, evacuation techniques, and detection of safety hazards. |
| Failed to provide residents with fire safety orientation including location of exits, fire extinguishers, and emergency procedures. |
| Failed to include residents in monthly fire drills and document problems or evacuation times related to residents. |
Report Facts
Residents present: 9
Direct Care Staff training hours: 16
Orientation training hours: 12
Resident evaluations reviewed: 4
Residents with deficient evaluations: 2
Residents with deficient ISPs: 2
Fire drills missing documentation: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint Intake #49675 to assess compliance with state regulations for Assisted Living Facilities.
Findings
No deficiencies were cited during the complaint survey, and the complaint was found to be unsubstantiated with no deficiencies noted.
Complaint Details
Complaint Intake #49675 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 17, 2020
Visit Reason
The inspection was conducted as an offsite video surveillance complaint survey related to COVID-19 infection prevention and control.
Findings
The facility was found in compliance with COVID-19 infection prevention and control measures during the offsite video surveillance complaint survey.
Complaint Details
The visit was complaint-related and the facility was found in compliance.
Inspection Report
Routine
Deficiencies: 0
Aug 12, 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
Jul 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 survey.
Inspection Report
Routine
Deficiencies: 0
Jul 14, 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
Abbreviated Survey
Deficiencies: 0
Jun 25, 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
Monitoring
Deficiencies: 0
Jun 10, 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
Monitoring
Deficiencies: 0
Apr 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 offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Mar 27, 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 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
Original Licensing
Deficiencies: 0
Sep 3, 2013
Visit Reason
An initial survey was completed on 09/03/13 for the state requirements of 7NMAC 8.2, Regulations for Assisted Living.
Findings
The facility was found to be in substantial compliance with 7NMAC 8.2, Regulations for Assisted Living. No Deficiencies were cited.
Inspection Report
Original Licensing
Capacity: 16
Deficiencies: 0
Nov 20, 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.
Report
File
survey_EV3M11.pdf
Report
File
survey_BZU611.pdf
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