Inspection Report
Routine
Deficiencies: 0
Aug 11, 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 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 survey.
Inspection Report
Routine
Deficiencies: 0
Jul 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 survey.
Inspection Report
Routine
Deficiencies: 0
Jun 11, 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
May 22, 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
May 5, 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 28, 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 30, 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 17, 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
Routine
Census: 8
Deficiencies: 9
May 26, 2016
Visit Reason
A full onsite routine survey was conducted to assess compliance with state regulations for assisted living facilities, including a complaint investigation which was unsubstantiated.
Findings
The facility was found deficient in multiple areas including staff training, incomplete admission agreements, missing resident evaluations and individual service plans, medication storage and handling, nutrition and food safety, maintenance of building and grounds, corridor obstructions, and lack of a required fire safety equivalency system survey.
Complaint Details
A complaint investigation for intake NM #29954 was unsubstantiated with no deficiencies cited.
Deficiencies (9)
| Description |
|---|
| Five direct care staff failed to receive annual re-certification training for assisting with medication delivery. |
| Admission agreements were incomplete for 1 current and 2 former residents, missing key elements such as facility rules, refund provisions, staffing ratios, and medication authorization. |
| Resident evaluations were not completed for 1 current and 2 former residents, lacking documentation of multiple required functional and health status areas. |
| Individual Service Plans (ISPs) were not developed or implemented within 10 days of admission for 1 current and 2 former residents, missing required elements. |
| Medication refrigerator lacked a lock and insulin was stored with food in the kitchen refrigerator. |
| Two cans of automotive starting fluid were stored in the food storage area with residents' food. |
| An outdoor light fixture by an approved exit was missing a bulb and cover, exposing electrical circuitry. |
| Furniture obstructed the paths to two approved emergency exits, reducing evacuation width below required minimums. |
| The facility lacked a Fire Safety Equivalency System (FSES) survey for the residents, as required annually. |
Report Facts
Direct Care Staff missing medication training: 5
Residents reviewed for admission agreement completeness: 8
Residents missing evaluations: 3
Residents missing ISPs: 3
Residents in facility census: 8
Temperature range for refrigerator: 35
Temperature range for refrigerator: 41
Temperature for hot foods: 140
Inspection Report
Complaint Investigation
Deficiencies: 2
May 12, 2009
Visit Reason
The inspection was conducted due to a complaint or regulatory review regarding the facility's failure to maintain documentation that the Employee Abuse Registry was checked for certain staff members, and failure to have clearance documentation from the New Mexico Care Givers' Criminal History Screening Program for some staff.
Findings
The facility failed to maintain documentation that the Employee Abuse Registry was checked for 4 sampled staff members and failed to have clearance letters from the Criminal History Screening Program for 2 of 4 sampled staff. The administrator acknowledged these deficiencies during interviews.
Complaint Details
The visit was complaint-related due to failure to check the Employee Abuse Registry and lack of clearance letters from the Criminal History Screening Program for certain staff. The administrator acknowledged these issues during interviews.
Deficiencies (2)
| Description |
|---|
| Failure to maintain documentation that the Employee Abuse Registry was checked for 4 sampled staff members. |
| Failure to have clearance documentation from the New Mexico Care Givers' Criminal History Screening Program for 2 of 4 sampled staff. |
Report Facts
Sampled staff records reviewed: 4
Staff without Employee Abuse Registry documentation: 4
Staff without Criminal History Screening clearance: 2
Hire dates noted: Staff #3 hired 01/26/07, Staff #4 hired 02/04/09
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 22, 2009
Visit Reason
The inspection was conducted as a result of a complaint survey (complaint #26819) regarding medication administration and consent issues at Heartfelt Manor Incorporate, an assisted living facility.
Findings
The facility failed to obtain written consent from eight sampled residents or their designees for medication assistance. Additionally, medication administration errors were found, including unlicensed staff administering suppository medications and failure to conduct required finger stick blood sugar tests for some residents.
Complaint Details
The complaint investigation was substantiated as the facility failed to obtain consent for medication assistance for eight residents and had medication administration deficiencies.
Deficiencies (2)
| Description |
|---|
| Failure to obtain written consent from residents or their designees for medication assistance. |
| Medication administration errors including unlicensed staff administering suppository medications and failure to conduct finger stick blood sugar tests as ordered. |
Report Facts
Number of residents without consent: 8
Number of sampled residents reviewed: 8
Date of survey completion: Jan 22, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny Mullins | Administrator | Interviewed regarding consent forms and medication administration; signed the report. |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 2
Dec 5, 2006
Visit Reason
Annual inspection survey conducted on 12/05/2006 to assess compliance with resident record keeping and building construction regulations at Heartfelt Manor Incorporate.
Findings
The facility failed to complete the resident assessment for 1 of 8 residents and did not complete evacuation ratings for all 8 residents. Building construction and fire safety requirements were reviewed with plans for corrective actions including weekly chart reviews and safety survey reports.
Deficiencies (2)
| Description |
|---|
| Failed to complete the resident assessment for 1 of 8 residents. |
| Failed to complete and maintain facility evacuation ratings for 8 of 8 residents. |
Report Facts
Residents with incomplete assessments: 1
Residents without evacuation ratings: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherry McCullough | Owner interviewed who confirmed inability to find resident assessment and incomplete evacuation ratings. |
Inspection Report
Original Licensing
Deficiencies: 2
Feb 21, 2006
Visit Reason
The inspection was an initial survey conducted at Heartfelt Manor to assess compliance with adult residential care facility regulations, focusing on personnel policies and resident records.
Findings
The facility failed to provide ongoing, duty-specific training for staff members and did not maintain recent updated history and physical reports for residents. Deficiencies were noted in personnel training documentation and resident record maintenance.
Deficiencies (2)
| Description |
|---|
| Failure to provide ongoing, duty-specific training for staff members from 09/15/2005 to 02/20/2006, including lack of documentation of in-service training and medication training. |
| Failure to provide a physician's history and physical report within thirty days of admission for two of five residents, and lack of recent updated history and physical reports for residents #1 and #3. |
Report Facts
Date survey completed: Feb 21, 2006
Number of residents reviewed for records: 5
Date requirement to be met: Mar 21, 2006
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #1 | Interviewed regarding in-service training and personnel file review | |
| Medical Director | Medical Director | Named in relation to failure to provide training and resident record updates |
| Facility Owner | Interviewed regarding training and resident record deficiencies |
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