Inspection Reports for
Lakeview Christian Home of the Southwest, Inc.
1905 W Pierce St, Carlsbad, NM, 88220
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
109% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the accuracy of the Minimum Data Set (MDS) assessment and safeguarding of resident personal health information.
Complaint Details
The visit was complaint-related, focusing on the accuracy of the MDS assessment and safeguarding of resident information. The deficiencies were substantiated as the MDS Coordinator and Director of Nursing confirmed the issues.
Findings
The facility failed to ensure the accuracy of the MDS assessment for one resident who had a fall that was not recorded, and failed to safeguard resident personal health information by leaving a list of residents with vital sign readings in plain view, potentially exposing confidential information of 38 residents.
Deficiencies (2)
Failure to ensure the Minimum Data Set Assessment (MDS) was accurate for one resident who had an unwitnessed fall not recorded in the MDS.
Failure to safeguard resident personal health information by leaving a list of residents with vital sign readings in plain view, potentially exposing confidential information.
Report Facts
Residents affected: 1
Residents affected: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed the MDS assessment inaccuracy for resident #1 | |
| Director of Nursing | Confirmed that personal health information should be safeguarded and was not | |
| ST #1 | Confirmed that the clipboard with resident information was left face up and visible |
Inspection Report
Routine
Census: 79
Deficiencies: 5
Date: Apr 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, and facility operations at Northgate Unit of Lakeview Christian Home.
Findings
The facility was found deficient in multiple areas including inaccurate PASRR screening, incomplete and inaccurate care plans for residents, failure to lock treatment carts, and failure to ensure staff wore hairnets in the kitchen. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failed to ensure the Pre-admission Screening and Resident Review (PASRR) assessment was accurate for 1 of 2 residents reviewed.
Failed to develop and implement an accurate, person-centered comprehensive care plan for 2 of 4 residents reviewed.
Failed to revise care plans within 7 days of comprehensive assessment for 2 of 4 residents reviewed.
Failed to ensure all treatment carts were locked while unattended, potentially affecting 18 residents.
Failed to ensure food was prepared and served under sanitary conditions when staff failed to wear hairnets in the kitchen, likely affecting all 79 residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 18
Residents affected: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding PASRR accuracy and care plan deficiencies | |
| Case Manager #1 | Confirmed treatment cart was unlocked | |
| Registered Nurse #1 | Confirmed and locked treatment cart | |
| Assistant Dietary Manager | Confirmed staff should wear hairnets in kitchen |
Inspection Report
Routine
Capacity: 76
Deficiencies: 14
Date: Mar 29, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, medication management, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, inadequate care plan revisions, failure to provide timely transfer and bed hold notices, medication management issues, unlocked medication and treatment carts, improper storage of insulin, failure to maintain call light systems, inadequate infection control practices, and incomplete staff training on dementia care and abuse reporting.
Deficiencies (14)
Failed to provide reasonable accommodation of resident needs for bedside table placement within reach for residents #37 and #41.
Failed to provide a homelike environment due to unrepaired broken roof tiles in the activity room affecting 76 residents.
Failed to provide timely written transfer notices and bed hold policy notices to residents and representatives for 6 residents reviewed for hospitalization.
Failed to ensure accurate Minimum Data Set (MDS) assessments for resident #58.
Failed to develop and revise care plans timely and include required interdisciplinary team members for 10 residents.
Failed to provide treatment and care according to orders for residents #59 and #65, including delayed antibiotics and failure to apply compression stockings.
Failed to keep treatment carts locked and ensure fall mats were placed for resident #41.
Failed to ensure licensed pharmacist's recommendations were followed or rationale documented for residents #36 and #41 regarding medication adjustments.
Failed to store medications properly, including unlocked medication carts, loose medications, and improper insulin storage.
Failed to serve food under sanitary conditions by not performing hand hygiene when distributing food trays and assisting residents.
Failed to ensure nasal cannulas were labeled with change dates for residents #14, #65, and #179.
Failed to implement a comprehensive antibiotic stewardship program including 48-72 hour antibiotic timeouts.
Failed to ensure call lights were within reach and functioning properly for 10 residents.
Failed to provide staff education on dementia care and abuse, neglect, and exploitation reporting for 4 staff members.
Report Facts
Residents affected: 76
Residents affected: 6
Residents affected: 10
Residents affected: 53
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #21 | Confirmed failure to wear compression stockings and lack of awareness of order | |
| DON | Director of Nursing | Confirmed multiple deficiencies including medication storage, care plan issues, and call light expectations |
| MDS Coordinator | Confirmed inaccuracies in MDS assessments and care plan revisions | |
| CNA #23 | Confirmed residents' bedside tables out of reach and fall mat missing | |
| RN #32 | Confirmed unlocked medication and treatment carts | |
| Administrator | Confirmed facility policies and deficiencies in notification and training |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 7, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, infection control, and facility environment at Northgate Unit of Lakeview Christian Home.
Findings
The facility was found deficient in multiple areas including failure to provide adequate hot water in resident bathrooms, inadequate restorative nursing services, insufficient behavioral health care follow-up, unsecured medication storage rooms, improper food temperature control, inaccurate medical record documentation, and failure to maintain infection prevention protocols including PPE use and proper storage of medical supplies.
Deficiencies (7)
Failed to provide hot enough water in residents' bathroom sinks in rooms 406 and 417.
Failed to ensure resident #12 received restorative nursing services as ordered.
Failed to ensure residents #12 and #386 received necessary behavioral health care and psychiatric follow-up while on psychotropic medications.
Failed to secure medication storage rooms by propping doors open and leaving doors unlocked.
Failed to serve food at safe temperature; soup served to resident #17 was not temperature checked to ensure 165°F.
Failed to maintain accurate medical records for residents #29 and #289, including late documentation of medication administration and incorrect PASRR documentation.
Failed to maintain infection prevention measures including staff not wearing required PPE for resident #12 on contact precautions and storing medical supplies on the floor in medication rooms.
Report Facts
Residents affected: 2
Restorative nursing frequency: 6
Medication late documentation counts: 9
Medication administration times: 3
Medication administration times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #6 | Registered Nurse | Confirmed restorative nursing frequency and behavioral health care deficiencies for resident #12 |
| Physical Therapist #2 | Physical Therapist | Confirmed restorative nursing expectations for resident #12 |
| Director of Nursing | Director of Nursing | Confirmed restorative nursing orders, psychiatric follow-up requirements, and medication documentation issues |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Observed not wearing required PPE in resident #12's room |
| Assistant Dietary Manager | Assistant Dietary Manager | Observed serving soup without temperature check |
| Registered Nurse #1 | Registered Nurse | Observed medication room door propped open and confirmed it should be locked |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed medication room door unlocked and confirmed it should be locked |
| Infection Preventionist | Infection Preventionist | Confirmed PPE requirements for resident #12 and infection control deficiencies |
Inspection Report
Deficiencies: 0
Date: Jun 8, 2020
Visit Reason
The visit was conducted as a COVID Offsite Surveillance.
Findings
No specific deficiencies or findings are detailed in the report beyond the initial comment indicating COVID Offsite Surveillance.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 15, 2020
Visit Reason
Offsite Surveillance Review 2 was conducted related to COVID 19 infection prevention and control.
Findings
No deficiencies were cited during the COVID 19 infection prevention and control review.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Fleming | Surveyor | Conducted the Offsite Surveillance Review related to COVID 19 infection prevention and control. |
Inspection Report
Routine
Deficiencies: 0
Date: 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
Date: 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
Complaint Investigation
Census: 14
Deficiencies: 1
Date: Mar 5, 2015
Visit Reason
A complaint investigation for intake NM00029603 and an On-site/Monitoring survey were completed on 03/05/15 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Complaint Details
The complaint was substantiated with no deficiencies cited as a result of the investigation.
Findings
The complaint was substantiated with no deficiencies cited as a result of the investigation. A deficiency was cited as a result of the On-site/Monitoring survey related to failure to ensure all staff received first aid training.
Deficiencies (1)
Facility failed to ensure that all staff were provided first aid training, which could result in residents not receiving immediate first aid when needed.
Report Facts
Residents present: 14
Staff without first aid training: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 13, 2009
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to convene team meetings to determine admission/retention appropriateness for residents requiring nursing services.
Complaint Details
The complaint investigation found that the facility did not convene required team meetings for residents R#1, R#2, R#3, and R#4 who require nursing services. The administrator acknowledged this during an interview on 08/11/09 at 12:30 PM.
Findings
The facility failed to convene team meetings for 4 residents requiring nursing services to determine if admission or retention was appropriate, as required by regulation. The administrator acknowledged no team meetings were held for these residents.
Deficiencies (1)
Failure to convene team meetings to determine admission/retention appropriateness for 4 residents requiring nursing services.
Report Facts
Residents affected: 4
Days to submit documentation: 5
Date of interview: Aug 11, 2009
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 2, 2008
Visit Reason
The inspection was conducted to assess compliance with New Mexico Regulations Governing Adult Residential Care Facilities.
Findings
No deficiencies were cited; the facility was found to be in compliance with all applicable New Mexico regulations.
Inspection Report
Annual Inspection
Census: 19
Capacity: 35
Deficiencies: 1
Date: May 17, 2007
Visit Reason
The inspection was conducted as an annual Life Safety Code survey for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure all fire protection systems, including smoke barriers and doors in smoke barriers, were maintained in safe and functioning condition. Specifically, self-closing devices on several doors were disabled or removed, preventing doors from closing and latching as required.
Deficiencies (1)
Door openings in smoke barriers did not have the required 20-minute fire protection rating or proper self-closing devices were disabled or removed, preventing doors from closing and latching as required.
Report Facts
Licensed capacity: 35
Census: 19
Inspection date: May 17, 2007
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Stated unawareness of disabled self-closing devices but explained intent to allow resident access |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 16, 2007
Visit Reason
The inspection was conducted to assess compliance with emergency handling requirements, specifically to verify that emergency numbers were posted near telephones in the assisted living facility.
Findings
The facility failed to post a list of emergency numbers by business telephones in the Assisted Living facility. No residents were adversely affected, but the deficiency was noted during the inspection.
Deficiencies (1)
Failure to post a list of emergency numbers, including Fire Department, Police Department, Ambulance Services, Poison Control, Licensing and Certification Bureau, Adult Protective Services, and Ombudsman near each public telephone in the facility.
Report Facts
Date of initial tour: Apr 16, 2007
Date of interview with Hostess: Apr 16, 2007
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Stafford | Administrator | Signed the statement of deficiencies and plan of correction |
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