Inspection Reports for Kingston Residences of Santa Fe
2400 Legacy Court Santa Fe, NM 87507, NM, 87507
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Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Aug 11, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint intakes related to the facility's compliance with state regulations for Assisted Living for Adults.
Findings
No deficiencies were cited during the complaint survey completed on 08/11/2025. The complaint intakes investigated resulted in no deficiencies cited.
Complaint Details
Complaint intake numbers were investigated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 6
Mar 27, 2025
Visit Reason
The inspection was conducted as a complaint survey based on a complaint intake regarding the facility's compliance with state regulations for assisted living facilities for adults.
Findings
The facility was found deficient in multiple areas including failure to ensure staff completed required annual training, failure to retain a resident presenting imminent physical threat, failure to revise resident evaluations and individual service plans after significant changes, failure to report incidents of abuse to the licensing authority timely, and failure to protect residents from resident-to-resident physical abuse.
Complaint Details
Complaint Intake NM was investigated and deficiencies were cited related to staff training, resident safety, evaluation and service plan updates, incident reporting, and resident rights violations.
Deficiencies (6)
| Description |
|---|
| Two staff members failed to complete 12 hours of annual training as required. |
| The facility failed to retain a resident who presented an imminent physical threat or danger to self or others. |
| Resident evaluations were not revised after significant changes in health status for multiple residents. |
| Individual Service Plans (ISPs) were not revised timely to reflect significant changes in residents' health status and did not include behavioral interventions. |
| The facility failed to report incidents of resident-to-resident and resident-to-staff abuse to the licensing authority within 24 hours and failed to conduct and submit investigation reports within 5 business days. |
| The facility failed to ensure one resident was free from resident-to-resident physical abuse. |
Report Facts
Resident Census: 48
Resident Census: 37
Incident counts: 15
Incident counts: 13
Incident counts: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Witnessed resident abuse incident and confirmed details during interview | |
| Nurse #2 | Failed to complete annual training for 2023 and 2024 | |
| Nurse #3 | Prepared internal incident report documenting resident abuse | |
| DCS #2 | Failed to complete annual training for 2024 | |
| Executive Director | Confirmed training deficiencies, incident reporting failures, and resident discharge plans during interviews |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Jul 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Intake NM67420 and NM58347, with deficiencies cited in one complaint and none in the other.
Findings
The facility was found deficient for including incorrect information in a resident discharge notice regarding appeal rights, failure to protect resident confidentiality by misplacing another resident's paperwork, and neglect by leaving a resident in a chair all night without staff checking on them as required.
Complaint Details
Complaint Intake NM67420 was investigated with deficiencies cited; Complaint Intake NM58347 was investigated with no deficiencies cited.
Deficiencies (3)
| Description |
|---|
| Discharge notice included incorrect information about residents' right to appeal discharge to the New Mexico Department of Health. |
| Failure to protect confidentiality of resident records; another resident's paperwork was found on a resident's dresser. |
| Resident neglect: Resident #3 was left in a chair all night on 05/23/23 without staff checking or putting the resident to bed as required by the individual service plan. |
Report Facts
Resident census: 59
Days to file appeal: 10
Date of discharge notice: 2023
Date of resident evaluation: 2023
Date resident left in chair: 2023
Date of individual service plan: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Choman | Executive Director | Signed the report form |
| DCS #5 | Direct Care Staff | Interviewed and confirmed resident left in chair all night |
| DCS #6 | Direct Care Staff | Interviewed regarding night shift duties and resident care |
| DCS #7 | Direct Care Staff | Interviewed regarding night shift duties and resident care |
| Administrator | Interviewed and confirmed incorrect discharge notice information | |
| DON | Director of Nursing | Interviewed regarding resident confidentiality breach |
Inspection Report
Follow-Up
Census: 68
Deficiencies: 3
Nov 8, 2022
Visit Reason
The visit was a Revisit/Follow-up survey completed on 11/08/22 to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living for Adults, following previous deficiencies.
Findings
The facility was found deficient in ensuring Employee Abuse Registry (EAR) clearances were completed prior to hire for several direct care staff, and in timely reporting and investigating incidents to the Licensing Authority. Additionally, medication administration records (MARs) lacked required information such as brand/generic names and dosages for multiple residents. These deficiencies could negatively affect resident safety and care.
Deficiencies (3)
| Description |
|---|
| Failed to ensure that direct care staff had completed Employee Abuse Registry clearances prior to hire. |
| Failed to report suspected or known incidents of resident abuse, neglect, or exploitation to the Licensing Authority within required timeframes and failed to conduct and document investigations within five business days. |
| Medication Administration Records (MARs) did not include required information such as diagnosis/reason for medication, brand and generic names, and dosages for multiple residents. |
Report Facts
Residents affected by EAR clearance deficiency: 68
Residents with incident reporting deficiencies: 6
Residents with MAR deficiencies: 9
Total residents on census: 68
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 8
Feb 1, 2022
Visit Reason
The survey was a Full Onsite/Complaint survey conducted for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living, including investigation of multiple complaints, most of which were unsubstantiated except Complaint NM#53116 which was unsubstantiated with deficiencies cited.
Findings
The facility was found deficient in multiple areas including staff training documentation, incident reporting, medication administration records lacking brand/generic names and dosages, unsafe storage of oxygen tanks, food safety and sanitation violations, hazardous storage of chemicals, maintenance issues including fire safety and emergency lighting, and obstructed emergency exit routes.
Complaint Details
Complaint NM#53116 was unsubstantiated with deficiencies cited. Other complaints investigated were unsubstantiated with no deficiencies.
Deficiencies (8)
| Description |
|---|
| Failed to ensure Direct Care Staff completed required 16 hours supervised training and 12 hours annual training with documentation available onsite. |
| Failed to report incidents of possible abuse, neglect, or exploitation to Licensing Authority within required 24 hours or next business day. |
| Failed to ensure oxygen cylinder tanks were stored securely and protected from accidental damage or dislocation. |
| Medication Administration Records did not include both brand and generic names and dosage for multiple residents' medications. |
| Food stored in refrigerators and freezers were not consistently covered, dated, or labeled; unused leftovers were not discarded after three days; daily temperature logs for refrigerators, freezers, and steam tables were not maintained; kitchen sanitation issues including unlocked cleaning supplies and exposed knives in memory care kitchen. |
| Failed to maintain Fire Suppression System riser room free from safety hazards; combustible materials stored near fuel fired hot water heater. |
| Failed to ensure emergency lighting was operational in all required areas. |
| Emergency exit routes were obstructed by furniture, medical equipment, and other objects blocking safe egress. |
Report Facts
Residents at risk due to staff training deficiencies: 71
Residents at risk due to oxygen storage deficiencies: 71
Residents at risk due to food safety deficiencies: 71
Residents at risk due to hazardous storage and maintenance deficiencies: 71
Residents at risk due to emergency lighting deficiencies: 71
Residents at risk due to obstructed emergency exit routes: 71
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 survey.
Inspection Report
Abbreviated Survey
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
Jul 1, 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 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
May 7, 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
Abbreviated Survey
Deficiencies: 0
Apr 16, 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 1, 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
Follow-Up
Deficiencies: 0
Feb 14, 2020
Visit Reason
The visit was a Revisit/Follow-Up survey to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the Revisit/Follow-Up survey completed on 02/14/20.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Oct 29, 2019
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted due to a substantiated complaint (NM#40598) regarding compliance with state regulations for assisted living.
Findings
The facility was found deficient in ensuring staff qualifications, specifically failing to verify Employee Abuse Registry clearance and timely submission of caregiver criminal history screening for employees. Additionally, resident admission agreements lacked required refund provisions upon death as mandated by state law.
Complaint Details
Complaint NM#40598 was substantiated with deficiencies cited related to staff qualifications and admission agreement compliance.
Deficiencies (2)
| Description |
|---|
| Failure to ensure employees were cleared by the Employee Abuse Registry prior to hire and failure to submit caregiver criminal history screening applications and fingerprints within 20 days of hire. |
| Resident admission agreements for 3 of 5 reviewed residents did not include a refund provision upon death in compliance with state regulations and Senate Bill 0335-2013. |
Report Facts
Resident census: 104
Employees reviewed: 1
Residents reviewed: 5
Residents non-compliant: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2017
Visit Reason
A complaint survey for intake NM#0030261 was completed for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake NM#0030261 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 17, 2017
Visit Reason
The inspection was conducted as a complaint survey related to state requirements for Assisted Living under 7 NMAC 8.2.
Findings
No deficiencies were cited as a result of the complaint survey. The complaint NM00030129 was unsubstantiated with no deficiencies found.
Complaint Details
Complaint NM00030129 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 17, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Kingston Residence of Santa Fe, related to regulatory oversight and compliance.
Findings
The document contains an initial comments section but does not provide specific findings or deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 14, 2016
Visit Reason
A complaint survey was conducted for intakes NM#30003 and NM#30004 to assess compliance with state requirements for Assisted Living under 7 NMAC 8.2.
Findings
The complaints were found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
The complaints investigated were unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 8
Nov 24, 2015
Visit Reason
A full onsite survey was completed for the New Mexico requirements for Assisted Living for Adults, including investigation of two complaints which were unsubstantiated with no deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to obtain an amended license for change of administrator, staff qualifications and training deficiencies, incomplete resident records, incomplete resident evaluations, medication management issues, and food service sanitation and safety violations.
Complaint Details
Two complaints were investigated, NM# 29801 and NM# 29845, both were unsubstantiated with no deficiencies cited.
Deficiencies (8)
| Description |
|---|
| Failed to obtain an amended License from the Licensing Authority for a change of Administrator within ten (10) business days of the change. |
| Failed to comply with Caregivers Criminal History Screening Requirements and Employee Abuse Registry for direct care staff and volunteers, and failed to ensure transportation staff have required documentation. |
| Failed to provide required staff training including 16 hours of supervised training prior to unsupervised care and 12 hours of annual training. |
| Resident records were incomplete and not organized with a table of contents; missing photographs, social history, language spoken, and other required information. |
| Resident evaluations for some residents were not reviewed or updated at least every six months or with significant change in condition. |
| Failed to ensure proper medication storage including separation of oral and topical medications, locked medication refrigerators, removal and destruction of discontinued medications, and secure storage of oxygen tanks. |
| Medication administration was not always performed by licensed or certified personnel; Medication Administration Records (MARs) were incomplete, lacking start dates, prescriber names, diagnoses, documentation of desired results for PRN medications, and full signatures. |
| Failed to post weekly menu, ensure all garbage containers had lids, and ensure all open food was labeled and dated in accordance with safe food storage practices. |
Report Facts
Resident census: 82
Number of Private Caregivers not screened: 12
Number of residents reviewed for medication issues: 9
Number of residents reviewed for record completeness: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Technician #1 | Medication Technician/Resident Assistant | Observed administering medication and interviewed regarding medication administration training |
| Clinical Services Director | Interviewed regarding licensing, medication administration, resident records, and medication storage | |
| Dietary Manager | Interviewed regarding food service sanitation, garbage containers, and food labeling | |
| Business Office Manager | Interviewed regarding staff training documentation and transportation staff files | |
| RN #1 | Registered Nurse | Interviewed regarding discontinued medication storage |
| Facility Owner | Interviewed regarding staff training compliance |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 12
Nov 18, 2015
Visit Reason
A complaint investigation was conducted which was substantiated, leading to a complete Life Safety Code Survey of the facility.
Findings
Multiple deficiencies were found including maintenance issues with abrupt changes in floor elevation, ventilation problems, electrical system violations including lack of GFCI protection, fire alarm system deficiencies, lack of automatic sprinkler protection in certain areas, unsealed smoke barrier penetrations, improperly functioning stairwell doors, lack of fire department connection signage, absence of annual fire inspection certification, missing fire extinguisher at the generator area, and inadequate fire drill documentation.
Complaint Details
The complaint investigation (NM00029862) was substantiated, triggering a complete Life Safety Code Survey.
Deficiencies (12)
| Description |
|---|
| Abrupt changes in elevation of walking surfaces exceeding 1/4 inch at door threshold leading into stairwell. |
| Ventilation system in main dryer room not maintained; dryer vent crushed and combustible materials stored behind dryers. |
| Electrical outlets near water sources not equipped with Ground Fault Circuit Interrupters (GFCI). |
| Circuit breaker dedicated to fire alarm system not mechanically protected, identified, or labeled properly. |
| Fire alarm system and components not tested and inspected by certified company at least every 12 months. |
| Automatic fire sprinkler system not installed in Records Storage room as required. |
| Smoke barrier walls and ceilings not properly sealed from penetrations allowing smoke movement between compartments. |
| Stairwell door at east end of 100 corridor had a 1/2 inch gap at top, impairing smoke resistance and door latching. |
| Fire Department Connections (FDC) at multiple buildings and community building not identified with signage. |
| No evidence of annual fire inspection and certification by local fire authority. |
| Fire extinguisher missing at outdoor generator area. |
| Fire drills not conducted quarterly on every shift; records show gaps in fire drill frequency. |
Report Facts
Residents affected by abrupt floor elevation deficiency: 19
Residents affected by electrical GFCI deficiency: 71
Residents affected by fire alarm circuit breaker deficiency: 117
Residents affected by fire alarm testing deficiency: 117
Residents affected by sprinkler system deficiency: 19
Residents affected by smoke barrier penetration deficiency: 27
Residents affected by stairwell door deficiency: 12
Residents affected by missing FDC signage: 117
Residents affected by missing annual fire inspection: 117
Residents affected by missing fire extinguisher: 117
Residents affected by inadequate fire drills: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged multiple findings including abrupt floor elevation, ventilation issues, electrical deficiencies, fire alarm system issues, sprinkler system deficiency, smoke barrier penetrations, stairwell door gap, FDC signage, missing fire extinguisher, and fire drill deficiencies. |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Nov 18, 2015
Visit Reason
A complaint investigation was conducted on 11/18/15 due to allegations against the facility, which were substantiated. This led to a complete Life Safety Code Survey being conducted on the same day.
Findings
Deficiencies were cited as a result of the complete Life Safety Code Survey conducted on November 18, 2015. A revisit onsite survey was conducted on 10/03/2016, which also resulted in deficiencies being recited.
Complaint Details
All items in the complaint investigation (NM00029862) conducted on 11/18/15 were substantiated.
Report Facts
Deficiency surveys: 2
Inspection Report
Re-Inspection
Deficiencies: 0
May 26, 2015
Visit Reason
The visit was a revisit survey conducted to assess compliance with the New Mexico Requirements for Assisted Living for Adults, specifically referencing 7.8.2. NMAC.
Findings
A deficiency was cited during the revisit survey; however, no specific details about the deficiency or its severity are provided in the report.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Jan 12, 2015
Visit Reason
The inspection was conducted as a complaint survey related to potential exploitation of a resident at Kingston Residence of Santa Fe.
Findings
The facility failed to report an incident of potential exploitation against Resident #1 within 24 hours as required. The complaint was unsubstantiated, but the Executive Director was unaware of the incident reporting process.
Complaint Details
Complaint NM #29591 was investigated and found to be unsubstantiated. The facility did not notify the Health Facility Licensing and Certification Bureau about the potential misappropriation of resident funds.
Deficiencies (1)
| Description |
|---|
| Failure to report an incident of potential exploitation against Resident #1 within 24 hours of notification. |
Report Facts
Resident count: 57
Missing funds amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed and stated unawareness of incident reporting process |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 27, 2013
Visit Reason
The inspection was conducted based on two complaint intakes, 28924 and 29016. Complaint 28924 was unsubstantiated with no deficiencies cited, while complaint 29016 was substantiated with deficiencies cited.
Findings
The facility failed to protect a resident's right to humane care by inadequately describing, executing, and documenting daily services for Resident #1, including insufficient assistance with eating and personal care. Additionally, the facility failed to maintain the kitchen vent hood at optimum capacity, as it had a weak upward draw.
Complaint Details
Complaint 28924 was unsubstantiated with no deficiencies cited. Complaint 29016 was substantiated with deficiencies cited.
Deficiencies (2)
| Description |
|---|
| Failure to protect resident's right to humane care by inadequately describing, executing, and documenting daily services for Resident #1, including lack of assistance with eating and personal care. |
| Failure to ensure the kitchen vent hood was functioning at optimum capacity, with a weak upward draw noted. |
Report Facts
Dates of falls or instances Resident #1 was found on the floor: 05/09/12, 05/22/12, 06/09/12, 07/08/12, 08/11/12, 08/15/12, 10/20/12, 12/29/12
Observation dates and times: 03/08/2023 at 2:45pm and 5:30pm for Resident #1; 03/26/2013 at 8:30am for kitchen vent hood
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Chef | Confirmed that the upward draw on the kitchen vent hood was slight during interview on 03/26/2013. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2012
Visit Reason
The inspection was conducted as a complaint investigation for two intakes (#NM00028244 and #NM00028191) related to NMAC 7.8.2 regulations governing Assisted Living facilities.
Findings
One complaint (#NM00028244) was substantiated, while the other complaint (#NM00028191) was unsubstantiated.
Complaint Details
Complaint intake #NM00028244 was substantiated. Complaint intake #NM00028191 was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 19, 2011
Visit Reason
The inspection was conducted as a complaint investigation for two intakes (#NM00028244 and #NM00028191) regarding regulations governing Assisted Living facilities. One complaint was substantiated and the other was unsubstantiated.
Findings
The facility failed to ensure a safe environment for residents, specifically Resident #1 and Resident #2, due to the abusive and disruptive behavior of Visitor #1. Multiple staff interviews and incident reports documented verbal and physical abuse by Visitor #1 towards residents and staff, ongoing threats to resident safety, and unresolved issues as acknowledged by the Administrator.
Complaint Details
Two complaints were investigated: intake #NM00028244 was substantiated, and intake #NM00028191 was unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents were provided with a safe environment due to abusive behavior of a visitor towards residents and staff. |
Report Facts
Date of incident report: Nov 11, 2011
Date of interview: Dec 13, 2011
Date of interview: Dec 12, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | LPN | Interviewed regarding witnessing Visitor #1's abusive behavior towards residents and staff |
| Director #1 | Reported on Visitor #1's behavioral patterns and threats to resident safety | |
| Director #2 | Manager on Duty | Responded to incident on Alzheimer's Unit involving Visitor #1 |
| Caregiver #1 | Witnessed Visitor #1's outbursts towards Resident #2 | |
| Caregiver #2 | Drafted incident report dated 11/11/11 describing Visitor #1's behavior | |
| Administrator | Acknowledged ongoing unresolved situation with Visitor #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2010
Visit Reason
A complaint survey was conducted for Intake NM00027555.
Findings
The complaint was not substantiated and no deficiencies were cited.
Complaint Details
The complaint was not substantiated and no deficiencies were cited.
Inspection Report
Deficiencies: 4
Apr 8, 2010
Visit Reason
The inspection was conducted to assess compliance with resident rights and food management regulations at Kingston Residence of Santa Fe.
Findings
The facility was found deficient in ensuring residents were free from physical restraints, specifically a resident in the Memory Care Unit with full bed rails. Additionally, the facility failed to maintain proper food management practices, including improper storage of perishable frozen meats, lack of effective hair restraints for food handlers, and poor cleanliness of kitchen equipment and areas.
Deficiencies (4)
| Description |
|---|
| Failure to ensure residents were free of physical restraints, evidenced by a resident in the Memory Care Unit with full bed rails. |
| Failure to store perishable frozen meats at required temperatures; ground beef and roasts were improperly stored in kitchen sinks and open trays without cooling or running water. |
| Failure to use effective hair restraints by employees processing, preparing, or serving food, risking contamination. |
| Failure to maintain cleanliness of kitchen equipment and areas, including encrustation and buildup inside ice maker machines and air outlets. |
Report Facts
Date of survey: Apr 8, 2010
Packages of ground beef observed: 3
Roasts observed: 7
Minimum supply of perishable food: 3
Minimum supply of non-perishable food: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Culinary Director | Acknowledged findings related to food management deficiencies | |
| Administrator | Acknowledged findings related to kitchen cleanliness |
Inspection Report
Annual Inspection
Census: 96
Capacity: 105
Deficiencies: 13
Apr 6, 2010
Visit Reason
Annual survey conducted for the Life Safety Code portion of New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in multiple areas including fire safety construction and maintenance, electrical system issues, emergency lighting, fire alarm system deficiencies, exit signage, fire clearance inspections, ventilation system maintenance, and smoking area safety. These deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (13)
| Description |
|---|
| Facility failed to ensure 1-hour fire rated walls were properly maintained between mechanical rooms and residential areas. |
| Facility failed to report new construction and submit building and floor plans for review and approval prior to installing or upgrading equipment. |
| Electric water heater not installed per Uniform Plumbing Code; pressure relief valve improperly plumbed. |
| Fire and smoke barrier doors and walls not maintained; doors failed to latch and were impeded. |
| Self-closing device missing or disabled on doors to hazardous areas, including laundry room and furnace room. |
| Ventilation equipment not maintained or functioning properly; multiple exhaust fans failed to operate. |
| Emergency lighting not installed or not functioning in stairwells and exit passageways. |
| Electrical system components improperly installed; unapproved wiring and conduit issues observed. |
| Exit and directional signs missing or obstructed, not clearly marking paths of egress. |
| Facility failed to ensure annual fire inspection by local fire prevention authority; last inspection dated 6/26/2009 with no clearance report. |
| Fire alarm system deficiencies including missing pull station and unconnected sprinkler tamper switch. |
| Heating/cooling fresh air vertical duct between floors not equipped with isolation fire damper. |
| Smoking areas not properly identified with signs; ashtrays made of combustible plastic material. |
Report Facts
Licensed capacity: 105
Census: 96
Inspection date: Apr 6, 2010
Last fire inspection date: Jun 26, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged multiple findings during exit conference. | |
| Maintenance Director | Acknowledged multiple findings and provided explanations during inspection. | |
| Director of Maintenance | Acknowledged missing fire alarm pull station. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 27, 2010
Visit Reason
A complaint investigation was conducted on 01/27/2010 for NMAC 7.8.2-New Mexico Regulations Governing Adult Residential Care Facilities.
Findings
The complaint intake #NM00027435 was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint Intake #NM00027435 was unsubstantiated.
Inspection Report
Annual Inspection
Census: 88
Capacity: 105
Deficiencies: 2
Apr 24, 2009
Visit Reason
The inspection was conducted as an annual survey for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities, specifically focusing on Life Safety Code compliance.
Findings
The facility failed to ensure that the fire alarm system was inspected annually as required, and portable fire extinguishers were not inspected monthly as mandated. The fire alarm inspection was overdue, and several fire extinguishers were not inspected within the required timeframes.
Deficiencies (2)
| Description |
|---|
| Failure to ensure the fire alarm system was inspected at least annually; last inspection report available was dated 1/28/08. |
| Failure to inspect portable fire extinguishers monthly as required, including K-class, ABC fire extinguishers in various kitchen and service areas. |
Report Facts
Licensed capacity: 105
Census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding fire alarm system inspection and acknowledged findings about fire extinguisher inspections | |
| Administrator | Acknowledged findings about fire extinguisher inspections at the exit conference |
Inspection Report
Original Licensing
Deficiencies: 5
Apr 23, 2009
Visit Reason
The inspection was conducted as an original licensing survey to assess compliance with state regulations regarding custodial drug permits, medication administration, and related health and safety standards at Kingston Residence of Santa Fe.
Findings
The facility was found deficient in multiple areas including failure to store medications under locked conditions, improper medication administration practices by staff, incomplete documentation on Medication Administration Records (MAR), and lack of notification to residents' families regarding incident reporting requirements.
Deficiencies (5)
| Description |
|---|
| Failure to ensure medications were stored under locked conditions; medication cart was unlocked and unattended. |
| Staff failed to assist residents with medications according to professional standards; improper handling and administration of medications observed. |
| Incomplete documentation on Medication Administration Records (MAR) for insulin administration; missing entries and no notation for missed doses. |
| Failure to ensure licensed personnel conducted narcotic medication counts according to professional standards. |
| Facility failed to provide documentation of notification to residents' families/guardians regarding incident reporting requirements. |
Report Facts
Date survey completed: Apr 23, 2009
Medication cart unlocked time: 650
Medication cart unlocked time: 700
Number of drawers unlocked: 4
Staff trained to assist with medications: 1
Medication pass observation time: 720
Probation period: 90
Medication audit start date: Apr 1, 2009
Probation completion date: Jul 20, 2009
Corrective action completion date: May 8, 2009
Corrective action completion date: May 11, 2009
Corrective action completion date: May 22, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Medication Technician / Staff | Observed failing to sanitize hands, improperly administering medications, and placed on probation |
| Licensed Nurse #1 | Licensed Nurse | Responsible for keys to medication cart and involved in narcotic count; acknowledged medication administration errors |
| Resident Care Coordinator | Responsible for daily checks of medication carts and monthly audits of Medication Administration Records | |
| Executive Director | Interviewed regarding lack of documentation for incident reporting notification |
Inspection Report
Original Licensing
Deficiencies: 6
Mar 27, 2008
Visit Reason
The inspection was conducted as an original licensing survey for Kingston Residence of Santa Fe to assess compliance with regulations related to custodial drug permits and medication administration.
Findings
The facility failed to ensure medications were stored securely and properly, failed to have physician orders for certain medications, and did not ensure proper administration and monitoring of medications for residents, including oxygen use and PRN medications. Multiple deficiencies were noted related to medication storage, self-administration, and documentation.
Deficiencies (6)
| Description |
|---|
| Failure to store residents' medications in secure medication carts or locked compartments accessible only to authorized staff. |
| Resident #3 did not have physician orders for over-the-counter medications found in his apartment, and medications were disposed of without proper orders. |
| Facility failed to ensure that medications kept in residents' rooms were appropriate and had physician approval for self-administration. |
| Facility failed to ensure oxygen was administered per physician orders for Resident #3, who used portable oxygen and oxygen concentrator. |
| Facility failed to maintain a Medication Administration Record (MAR) documenting medications administered, including over-the-counter medications, for Resident #3. |
| Facility failed to ensure PRN medications were closely supervised and monitored. |
Report Facts
Deficiencies cited: 6
Resident sample size: 5
Date of survey completion: Mar 27, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bobby Yauger | Executive Director | Signed the plan of correction |
| Director of Nursing | Interviewed regarding medication storage and administration for Resident #3 | |
| Dr. Becker | Physician | Provided order for portable oxygen for Resident #3 |
Inspection Report
Annual Inspection
Census: 57
Capacity: 105
Deficiencies: 7
Aug 22, 2007
Visit Reason
The inspection was an annual life safety code survey conducted on 08/22/2007 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to meet several life safety code requirements including improper storage and securing of oxygen cylinders, inadequate ventilation in the oxygen storage room and janitor's closet, failure to ensure emergency lighting system testing, improper exit door hardware, and deficiencies in the automatic fire sprinkler system maintenance.
Deficiencies (7)
| Description |
|---|
| Oxygen cylinders were not secured in racks and were placed freestanding on the floor. |
| Oxygen storage room was not mechanically vented directly to the outside. |
| Plywood sheets protecting walls in oxygen storage room were removed and not replaced with one-hour fire resistant material. |
| Janitor's closet duct work was incorrectly installed and ventilation to the outside was not provided or functional. |
| Emergency lighting system was not periodically tested and documented as required; emergency battery backup light failed to illuminate. |
| Exit doors lacked proper panic hardware and some doors had door knob style hardware not suitable for egress. |
| Automatic fire sprinkler system was not properly maintained; sprinkler heads had lint and grease buildup. |
Report Facts
Licensed capacity: 105
Census: 57
Oxygen cylinders: 25
Additional oxygen cylinders ordered: 56
Inspection date: Aug 22, 2007
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed and acknowledged findings related to ventilation and fire sprinkler system. | |
| Memory Care Director | Interviewed and acknowledged findings related to ventilation and panic hardware installation. |
Inspection Report
Annual Inspection
Deficiencies: 4
Aug 20, 2007
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations for the Kingston Residence of Santa Fe, including admission policies, resident rights, medication administration, and staff training.
Findings
The facility was found deficient in several areas including failure to notify licensing authority of admission/retention exceptions, failure to ensure residents were free from physical restraints, incomplete medication administration documentation, and lack of required staff training documentation on abuse prevention. Plans of correction were submitted with specified completion dates.
Deficiencies (4)
| Description |
|---|
| Failed to submit documentation of comprehensive care plans to licensing authority for admission/retention exceptions for 4 of 4 residents. |
| Failed to ensure residents were free of physical restraints; bed rails were present on residents' beds. |
| Failed to ensure medications were administered and documented according to physician orders; missing signatures and documentation for medication administration. |
| Failed to maintain required documentation of ongoing training for abuse, neglect, and exploitation for 100% of facility staff. |
Report Facts
Deficiencies cited: 4
Medication orders reviewed: 10
Medication orders missing signature: 9
Employees trained: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbi Younger | Executive Director | Signed the plan of correction and involved in interview regarding correction of deficiencies. |
| Director of Health Services | Conducted audits, training, and oversight related to medication administration and staff training. | |
| Administrator | Interviewed regarding removal of bed rails and understanding of medication administration problems. | |
| Director of Nurses | Confirmed missing follow-up notation regarding medication administration issues. |
Inspection Report
Routine
Deficiencies: 8
Dec 21, 2004
Visit Reason
The inspection was a routine regulatory survey of Kingston Residence of Santa Fe to assess compliance with adult residential care facility regulations.
Findings
The facility was found deficient in multiple areas including personnel qualifications, admission and discharge planning, resident assessments, individual service plans, custodial drug permit possession and medication storage, housekeeping and laundry services, maintenance of building and grounds, and fire and safety training. Notably, a resident was admitted whose care needs exceeded the facility's scope and was discharged to a hospital without proper placement arrangements.
Deficiencies (8)
| Description |
|---|
| Failed to have documentation of qualifications for an employee to work in an adult residential care facility. |
| Admitted a resident for whom the facility could not meet care needs and failed to provide a discharge plan following hospital transportation. |
| Failed to provide or make available social activities to residents to promote well-being; activities were limited or absent on certain days. |
| Four of fifteen resident care plans were not signed by the nurse completing the review. |
| Failed to possess a current custodial drug permit and failed to properly store medications in locked compartments. |
| Failed to maintain a safe and clutter-free environment; hazardous exposed wires and cluttered storage areas were observed; poisonous and hazardous chemicals were stored in unlocked, resident-accessible areas. |
| Failed to maintain inside walls free of hazards and carpet free of tripping hazards; protruding nails and torn carpet seams were observed. |
| Failed to conduct fire drills for 3 of 11 months in 2004; documentation of fire drills was missing due to misfiling. |
Report Facts
Months without fire drills: 3
Unsigned care plans: 4
Inspection Report
Routine
Deficiencies: 17
Dec 21, 2004
Visit Reason
The inspection was a routine life safety and regulatory compliance survey of Kingston Residence of Santa Fe to assess housekeeping, maintenance, fire safety, electrical systems, fire alarms, sprinkler systems, and staff training.
Findings
The facility was found to have multiple deficiencies including dirty exhaust vents, malfunctioning fire doors, burnt out light bulbs, unsecured oxygen cylinders, inadequate exit lighting, unlabeled electrical panels, missing fire inspection and fire alarm inspection documentation, incomplete fire drills documentation, and sprinkler obstructions. Corrective actions were planned or underway for all deficiencies.
Deficiencies (17)
| Description |
|---|
| Dirty exhaust vents in bathroom and kitchen |
| Fire doors not closing and latching properly |
| Multiple burnt out light bulbs in corridors, stairwells, laundry, and resident rooms |
| Manual fire alarm pull station not anchored |
| Smoke detector covered by plastic making it inoperable |
| Dryer vent disconnected, venting into laundry room |
| Missing escutcheon plates on sprinkler heads |
| Electrical panel breakers labeled 'spare' but in use |
| Oxygen cylinders not secured in holders |
| Exit lighting battery backups not working or exit lights not illuminated |
| Lighting fixtures not protected from accidental breakage |
| Emergency lighting dim or not working |
| Fire inspection report not available |
| Fire alarm system inspection report not available |
| Automatic fire sprinkler system inspection reports not available; sprinkler obstructions found |
| Fire extinguisher missing inspection tag |
| Fire drills not conducted monthly or documentation incomplete |
Report Facts
Oxygen cylinders: 40
Fire drills conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bobbi Yauger | Executive Director | Sent fax requesting inspection; named in plan of correction |
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