Inspection Reports for Life Spire Assisted Living of North Albuquerque Acres
7500 Oakland Ave NE, Albuquerque, NM, 87113
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 7, 2025, identified deficiencies related to delayed follow-up reporting and care coordination for a resident with unusual behaviors and medication refusal. Earlier inspections showed a pattern of issues with incident reporting, care coordination, and documentation, including substantiated complaints about failure to report abuse and financial exploitation. Prior deficiencies mainly involved resident rights protection, staff training, medication administration, and facility maintenance. Complaint investigations were substantiated in several cases, particularly concerning incident reporting and resident protection, while some earlier complaints were unsubstantiated. The facility’s recent deficiencies reflect ongoing challenges similar to past findings, indicating a need for continued attention to reporting and care coordination processes.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
25 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 2
Date: Feb 7, 2025
Visit Reason
The inspection was a complaint survey completed on 02/07/25 to investigate deficiencies related to the state requirements of NMAC 8.370.14 for Assisted Living Facilities for Adults.
Complaint Details
Complaint Intake NM [redacted] was investigated with deficiencies cited. The complaint involved a resident found on the floor complaining of pain, with delayed submission of the facility's internal investigation report and failure to ensure hospice care coordination for a resident refusing medication and displaying unusual behaviors. The complaint was substantiated with cited deficiencies.
Findings
The facility failed to submit a Follow-Up Report within five business days for one resident incident and failed to ensure proper care coordination and intervention for a resident displaying unusual behaviors and refusing medication. The investigation revealed issues with incident reporting, care coordination with hospice, and documentation of resident care and medication administration.
Deficiencies (2)
Failure to submit Follow-Up Report within five business days of incident date.
Failure to ensure care coordination outreach to hospice for resident with unusual behaviors and refused medication.
Report Facts
Resident Census: 25
Incident date: Jan 21, 2024
Follow-Up Report submission date: Mar 13, 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
The inspection was conducted as an Offsite Complaint Survey related to complaint intake #45736 to determine compliance with state regulations for Assisted Living Facilities.
Complaint Details
Complaint intake #45736 was unsubstantiated with no deficiencies cited.
Findings
No deficiencies were cited during the Offsite Complaint Survey, and the complaint intake #45736 was found to be unsubstantiated with no deficiencies identified.
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 offsite surveillance 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: Mar 27, 2020
Visit Reason
An offsite surveillance survey was conducted related to Covid 19 infection and control.
Findings
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Date: 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
Date: Sep 27, 2019
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 09/27/19.
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
Date: May 23, 2019
Visit Reason
The inspection was conducted as a complaint survey related to substantiated allegations of abuse, neglect, and exploitation at the assisted living facility.
Complaint Details
Complaint Intake NM#35227 was substantiated with deficiencies cited related to failure to timely report and investigate incidents of financial exploitation and injuries to residents.
Findings
The facility failed to report incidents of abuse, neglect, and exploitation to the Licensing Authority within required timeframes and did not submit timely follow-up investigation reports. Specific incidents involved financial exploitation of residents by staff and failure to report and investigate injuries such as falls and bruises. The facility also failed to protect residents from financial abuse and misappropriation by staff.
Deficiencies (2)
Failure to report incidents of abuse, neglect, exploitation within 24 hours and submit follow-up investigation reports within 5 business days.
Failure to ensure resident rights including protection from financial abuse and misappropriation by facility staff.
Report Facts
Residents at risk: 24
Checks cashed by DCS #1: 2
Days late for incident report submission: 11
Days late for follow-up report submission: 37
Incident report dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DCS #1 | Direct Care Staff | Named in financial exploitation finding; terminated for exploitation of resident R #1. |
| DCS #2 | Direct Care Staff | Named in financial exploitation finding related to checks written by resident R #1. |
| Administrator | Conducted internal investigation of financial exploitation and reported incidents to Licensing Authority. | |
| House Manager | Confirmed failure to timely report incidents and submit follow-up reports. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 13, 2018
Visit Reason
The visit was a Revisit/Follow-up survey to verify compliance with state requirements for assisted living facilities.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 08/13/18 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 1, 2018
Visit Reason
The inspection was a Revisit/Follow-up survey completed on 05/01/18 to assess compliance with state requirements for Assisted Living under 7 NMAC 8.2 regulations.
Findings
The facility was found deficient in ensuring that Admission/Discharge Agreements reviewed for compliance were accurate and included required provisions such as termination conditions and refund policies. Specifically, agreements did not state that termination could occur if an appropriate placement was found, nor did they include prorated refund provisions in case of death as required by state statutes.
Deficiencies (2)
Admission/Discharge Agreements did not state that the facility can terminate the agreement if an appropriate placement has been found for the resident.
Admission/Discharge Agreements lacked a refund provision in case of death that complied with state statutes for a prorated refund.
Report Facts
Deficiency cited: 1
Date of Admission/Discharge Agreement reviewed: Jan 9, 2018
Date of Admission/Discharge Agreement reviewed: Apr 27, 2018
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 10
Date: Nov 22, 2017
Visit Reason
Deficiencies were cited during a Complaint survey completed on 11/22/17 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Complaint Details
Deficiencies were cited during a Complaint survey completed on 11/22/17. The complaint investigation found failures in staff training, incident reporting, resident record maintenance, medication administration, and facility safety. The complaint was substantiated with multiple findings of noncompliance.
Findings
The facility failed to ensure staff received proper training on incident reporting, admission and discharge agreements, resident records, medication administration, nutrition, maintenance, and other regulatory requirements. Several deficiencies were noted including missing documentation, incomplete resident records, unsafe medication practices, and inadequate facility maintenance.
Deficiencies (10)
Staff failed to receive training on incident reporting requirements for abuse, neglect, and exploitation.
Facility failed to complete admission agreements including refund policies and authorization forms.
Resident records were incomplete, missing documentation such as allergy information, physician contact, and service plans.
Medication administration deficiencies including missing signatures on medication count sheets and inaccurate medication records.
Facility failed to maintain clean and sanitary conditions, including dirty medication refrigerators and improper handling of soiled linens.
Electrical room was blocked and unsafe, preventing immediate access to electrical panels.
Public restroom doors were difficult to open from the inside, posing safety risks.
Facility failed to ensure proper storage and handling of medications, including locked medication refrigerators and accurate medication destruction records.
Facility failed to conduct timely investigations and reporting of incidents involving resident abuse or injury.
Facility failed to ensure staff received required hospice/palliative care training and to hold team meetings prior to admitting hospice residents.
Report Facts
Resident census: 24
Training hours: 16
Training hours: 12
Medication doses: 21
Medication doses: 18
Temperature degrees: 35
Temperature degrees: 41
Timeframe: 10
Timeframe: 15
Timeframe: 6
Timeframe: 24
Timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Named in findings related to lack of training, incident reporting, and record keeping. | |
| Direct Care Staff #4 | Named in findings related to medication administration and training deficiencies. | |
| Direct Care Staff #2 | Named in findings related to medication refrigerator and medication count sheet deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 6, 2017
Visit Reason
A Revisit/Follow-up survey was completed on 03/06/17 for survey dated 12/08/16 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
There were no deficiencies cited as a result of the survey.
Inspection Report
Original Licensing
Census: 11
Deficiencies: 6
Date: Dec 8, 2016
Visit Reason
The inspection was conducted as an initial survey for state requirements of assisted living regulations.
Findings
The facility was found deficient in staff training, admissions and discharge procedures, emergency handling, resident rights postings, fire extinguisher maintenance, and hospice care coordination. Specific deficiencies included lack of documented staff training hours, incomplete admission agreements, missing emergency phone numbers, uninspected fire extinguishers, and failure to hold required hospice admission team meetings.
Deficiencies (6)
Failed to ensure 16-hours of supervised training and 12-hours of orientation training for direct care staff and chef.
Admission/Discharge Agreements were incomplete and admission/retention team meetings were not convened prior to admitting/retaining residents on hospice or higher level care.
No list of emergency phone numbers posted near public phone accessible to residents and staff.
Telephone numbers for incident management hotline and state Ombudsman program were not posted in a conspicuous public place.
Fire extinguishers had not been inspected monthly by authorized personnel.
Failed to hold Admission/Retention Exception team meetings prior to admitting or retaining hospice residents.
Report Facts
Direct Care Staff training files reviewed: 4
Residents reviewed for admission agreement compliance: 4
Residents on census: 11
Fire extinguishers: 7
Hospice residents reviewed: 3
Hospice residents with missing team meetings: 2
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 10, 2016
Visit Reason
An Initial Life Safety Code Survey was conducted at the facility as per the provider's request to assess compliance for licensure.
Findings
The facility was found in substantial compliance with the Life Safety Code portion of New Mexico State Regulations for Assisted Living Facilities for Adults, and temporary licensure was recommended after documentation was submitted addressing all issues.
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