Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Feb 7, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate a complaint intake related to medication administration at the assisted living facility.
Findings
The facility failed to ensure that the Medication Administration Record (MAR) for one resident included both brand and generic names of medications as required by state regulations. No other deficiencies were cited during the complaint investigation.
Complaint Details
The complaint intake was investigated with no deficiencies cited except for the medication administration issue related to the MAR not including both brand and generic names for one resident. The complaint was related to medication administration.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that the medications listed on the Medication Administration Record (MAR) contained both brand and generic drug names for one resident. |
Report Facts
Census: 28
Residents reviewed: 28
Residents with deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Owner/Administrator | Confirmed during interview that the alternate drug name was excluded from the resident's November 2023 MAR |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 8
Jun 2, 2022
Visit Reason
A Complaint Survey was conducted on June 2, 2022, at Life Spire Assisted Living of Rio Rancho by the New Mexico Department of Health to determine compliance with state requirements for Assisted Living Facilities.
Findings
The survey found that the facility was not in compliance with participation requirements, citing deficiencies related to staff qualifications, resident records, incident reporting, medication administration, nutrition, safety, hospice care, and memory care units. Some complaints were substantiated with deficiencies cited, while others were unsubstantiated.
Complaint Details
Complaint Intake #50390 was unsubstantiated with no deficiencies cited. Complaint Intake #52767 was substantiated with deficiencies cited.
Deficiencies (8)
| Description |
|---|
| Failure to submit fingerprint applications for direct care staff within 20 days of hire. |
| Resident records were not maintained or available within 24 hours of request, risking neglect. |
| Failure to report incidents of possible abuse, neglect, or exploitation to the Licensing Authority within 24 hours. |
| Improper storage and labeling of medications and failure to document medication administration correctly. |
| Failure to maintain proper food storage, sanitation, and temperature controls in dietary services. |
| Emergency lighting and exit lighting not maintained or tested properly. |
| Windows had damaged or missing screens, creating safety hazards. |
| Failure to provide required training and documentation for hospice and memory care staff. |
Report Facts
Residents on census: 28
Fingerprint submission timeframe: 20
Incident reporting timeframe: 24
Medication administration review period: 72
Training hours required: 6
Memory care training hours: 12
Inspection Report
Routine
Deficiencies: 0
Aug 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 offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
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
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
Follow-Up
Deficiencies: 0
Jul 17, 2018
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, and the facility was found to be in substantial compliance.
Inspection Report
Follow-Up
Deficiencies: 1
Apr 27, 2018
Visit Reason
The visit was a Revisit/Follow-up survey conducted to assess compliance with state requirements for assisted living facilities, specifically regarding admission and discharge agreements.
Findings
The facility was found to have a repeat deficiency related to admission/discharge agreements for two residents, which did not include a refund provision in case of death that complied with state statutes requiring a prorated refund to the resident's estate for unused payments beyond the termination date.
Deficiencies (1)
| Description |
|---|
| Admission/Discharge Agreements for two residents did not include a refund provision in case of death that complied with state statutes for a prorated refund to the resident's estate. |
Report Facts
Residents with deficient Admission/Discharge Agreements: 2
Date of survey completion: Apr 27, 2018
Previous survey date: Nov 22, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Confirmed that the Admission/Discharge Agreements for residents #1 and #2 lacked the required refund provision. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Nov 22, 2017
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to investigate Complaint Intake NM#30218, which was found to be unsubstantiated.
Findings
The facility was cited for multiple deficiencies including failure to ensure proper admission agreements, resident evaluations, individual service plans, resident rights protections, medication administration, laundry services, fire extinguisher maintenance, and hospice care coordination. Specific issues included inadequate admission agreements for hospice residents, failure to update evaluations and ISPs with changes in condition, unsafe and unsanitary environment related to infection control, improper medication administration by unlicensed staff, unsecured laundry supplies, and lack of fire extinguisher inspections.
Complaint Details
Complaint Intake NM#30218 was unsubstantiated with deficiencies cited.
Severity Breakdown
Class B: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Admission agreements lacked refund provisions, termination clauses, and coordination with hospice/home health care. | — |
| Resident evaluations were not reviewed or updated when there was a change in condition for hospice residents. | — |
| Individual Service Plans (ISPs) were not reviewed or revised with changes in condition, lacked coordination with hospice providers, and missed expected goals and outcomes. | — |
| Facility failed to provide a safe and sanitary environment and did not implement infection control interventions for a resident diagnosed with a contagious infection. | Class B |
| Direct Care Staff failed to sign controlled medication count sheets for one resident. | — |
| Unlicensed Direct Care Staff administered medications to a resident unable to self-administer. | — |
| Laundry services failed to keep clean and soiled laundry separate, stored cleaning supplies unsecured and accessible to residents. | — |
| Fire extinguisher in laundry room had not been inspected since September 2010. | — |
| Individual Service Plans for hospice residents did not include documentation of coordination of care with hospice providers. | — |
Report Facts
Residents with deficient admission agreements: 5
Residents with deficient evaluations: 3
Residents with deficient ISPs: 3
Residents with missing controlled medication signatures: 1
Residents receiving hospice services with deficient ISPs: 2
Fire extinguishers inspected: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| House Manager | Confirmed deficiencies related to admission agreements, evaluations, ISPs, infection control, and hospice coordination. | |
| Direct Care Staff #7 | Observed dragging open bag of soiled adult briefs and confirmed laundry and fire extinguisher issues. | |
| Direct Care Staff #6 | Observed administering medication to resident unable to self-administer. | |
| Direct Care Staff #4 | Observed poor hand hygiene and improper trash handling. | |
| Direct Care Staff #5 | Observed poor hand hygiene after leaving isolation room. | |
| Administrator | Confirmed diagnosis and isolation status of resident #7 and lack of team meetings for hospice residents. |
Inspection Report
Original Licensing
Deficiencies: 0
May 9, 2013
Visit Reason
An initial survey was completed on May 9, 2013 for licensure under 7NMAC8.2, Regulations for Assisted Living Facilities.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Original Licensing
Capacity: 30
Deficiencies: 0
Oct 31, 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.
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