Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Jan 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation for the state requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults.
Findings
The facility failed to ensure that the Individual Service Plan (ISP) for one resident was reviewed and signed by a Licensed Practical Nurse, Registered Nurse, or Physician extender, which could likely cause harm if staff were unaware of resident needs.
Complaint Details
Complaint intake numbers were investigated and deficiencies were not cited for those complaints. The deficiency found related to the ISP review and signature was identified during the complaint investigation.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the resident's Individual Service Plan was reviewed and signed by licensed nursing staff or physician extender. |
Report Facts
Resident Census: 58
Resident Files Reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Confirmed that the resident's ISP was not reviewed or signed by licensed nursing staff during an interview. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 8
Dec 14, 2023
Visit Reason
The inspection was conducted as a Complaint/Full-Onsite survey for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities for Adults.
Findings
The facility was found deficient in several areas including custodial drug permits, medication administration by unlicensed staff, oxygen cylinder storage safety, nutrition and food service management, housekeeping, laundry services, hazardous areas, and window maintenance. These deficiencies posed risks of harm, injury, or death to residents.
Complaint Details
The visit was complaint-related with multiple complaint intakes investigated, all with no deficiencies cited except the main complaint that triggered the survey. The complaint investigation found multiple deficiencies posing risk of harm, injury, or death to residents.
Deficiencies (8)
| Description |
|---|
| Failure to have current custodial drug permits and proper storage and handling of medications and medical gases including oxygen cylinders. |
| Medication administration by Direct Care Staff who are not licensed nurses or certified health care professionals, resulting in medication errors and risks to residents. |
| Failure to ensure oxygen cylinder tanks were stored securely and protected from accidental damage or dislocation. |
| Failure to provide adequate nutrition and maintain proper food safety, sanitation, and temperature controls in the kitchen and food storage areas. |
| Housekeeping deficiencies including improper storage of combustibles and hazardous chemicals. |
| Laundry room access was unsecured and cleaning supplies were not properly stored, posing risk of harm to residents. |
| Hazardous areas such as storage rooms and mechanical rooms were not properly secured or maintained with fire protection measures. |
| Windows had damaged or missing screens, exposing residents to insects, allergens, and debris. |
Report Facts
Census: 43
Oxygen cylinder tanks unsecured: 3
Oxygen cylinder tanks total: 11
Laundry detergent containers unsecured: 2
Plastic gallon jars of condiments outdated: 10
Plastic bags of food items outdated: 6
Damaged window screens: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Named as providing census information and confirming risks related to deficiencies | |
| Facility Health and Wellness Director | Managed medication retraining and confirmed medication administration findings | |
| Director of Facility Operations | Confirmed oxygen cylinder storage conditions | |
| Facilities Maintenance Director | Ensured hazardous chemicals were secured and windows/screens maintained | |
| Executive Director | Confirmed hazardous items stored improperly in maintenance areas | |
| DCS #4 | Direct Care Staff observed administering medications incorrectly | |
| DCS #9 | Kitchen staff responsible for food preparation and service training deficiencies |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 6
Jul 7, 2021
Visit Reason
The inspection was a complaint survey completed on 07/07/21 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living, triggered by Complaint # NM51912 which was substantiated with deficiencies cited.
Findings
The facility was found deficient in multiple areas including staff qualifications, resident evaluations, resident rights, nutrition, housekeeping services, and employee abuse registry clearance. Specific issues included failure to ensure Employee Abuse Registry clearance prior to hire, incomplete resident evaluations within required timeframes, failure to protect resident rights, improper handling of a resident causing injury, lack of close-fitting lids on trash cans, and unsecured hazardous chemicals.
Complaint Details
Complaint # NM51912 was substantiated with deficiencies cited related to employee abuse registry clearance and resident safety.
Deficiencies (6)
| Description |
|---|
| Failure to ensure Direct Care Staff had been cleared by the Employee Abuse Registry prior to hire. |
| Failure to complete initial resident evaluations within 15 days prior to admission for some residents. |
| Failure to protect resident rights including providing written legal rights and ensuring privacy and safety. |
| Failure to ensure safety and welfare of a resident during transfers resulting in injury. |
| Failure to have close-fitting lids on two trash cans in the kitchen. |
| Failure to store cleaning supplies and hazardous chemicals in secure areas inaccessible to residents. |
Report Facts
Resident census: 49
Residents affected: 5
Residents affected: 1
Trash cans: 2
Dates of training: 2
Dates of training: 2
Date of purchase: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #3 | Direct Care Staff | Employee whose EAR clearance was not completed prior to hire and whose evaluation was not completed within 15 days prior to admission. |
| DCS #4 | Direct Care Staff | Employee whose EAR clearance was not completed prior to hire. |
| DCS #1 | Direct Care Staff | Employee who admitted to not using two-person transfer technique resulting in resident injury and was terminated. |
| Administrator | Confirmed EAR clearance issues and resident evaluation delays during interviews. | |
| Business Office Coordinator | Trained on new protocol and checklist for Employee Abuse Registry and auditing new hire files. | |
| Executive Director | Responsible for auditing new hire paperwork and conducting weekly walk-throughs to ensure compliance. | |
| Dining Services Director #12 | Confirmed trash cans in kitchen did not have close-fitting covers. |
Inspection Report
Routine
Deficiencies: 0
Aug 18, 2020
Visit Reason
An offsite 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
Deficiencies: 0
Jul 15, 2020
Visit Reason
An offsite 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
Deficiencies: 0
Jun 19, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection and prevention control.
Findings
No deficiencies were cited during the COVID-19 infection and prevention control survey.
Inspection Report
Routine
Deficiencies: 0
Mar 31, 2020
Visit Reason
An offsite 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
Jan 7, 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 01/16/2020.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Oct 18, 2019
Visit Reason
The inspection was conducted as a complaint survey related to substantiated complaint intake #NM39192 concerning the facility's failure to report incidents and submit follow-up investigation reports as required by state regulations.
Findings
The facility failed to report incidents or injuries of unknown origin to the Licensing Authority within 24 hours or the next business day and did not submit required follow-up investigation reports within 5 business days. Multiple unwitnessed incidents with apparent injuries were not reported timely, placing all 56 residents at potential risk.
Complaint Details
Complaint Intake #NM39192 was substantiated. The facility did not report multiple unwitnessed falls with injury within the required timeframe and failed to submit a 5-day follow-up investigation report for an incident involving resident #1 on 08/20/19 where CPR was initiated and the resident was transported to the hospital.
Deficiencies (2)
| Description |
|---|
| Failure to report incidents or injuries of unknown origin to the Licensing Authority within 24 hours or the next business day. |
| Failure to submit follow-up investigation reports to the Licensing Authority within 5 business days from the date the incident occurred. |
Report Facts
Residents on census: 56
Incident report dates: 6
Follow-up report timeframe: 5
Incident report timeframe: 24
Inspection Report
Original Licensing
Census: 61
Deficiencies: 8
Apr 8, 2019
Visit Reason
Initial survey completed on 04/08/19 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility was found deficient in multiple areas including failure to apply for an amended license after administrator change, incomplete admission/discharge agreements lacking refund upon death policy, lack of team meetings and coordination for hospice residents, missing vaccination records for pets, incomplete resident evaluations and individual service plans, lack of required transportation training for drivers, and medication administration records missing brand/generic names.
Deficiencies (8)
| Description |
|---|
| Failed to apply for an amended license within ten business days after change of Administrator. |
| Admission/Discharge agreements did not include a refund upon death policy and lacked required team meetings and coordination for hospice residents. |
| Pets (3 cats) living in the facility did not have current vaccinations and vaccination records were not on file. |
| Resident evaluations were not reviewed and updated every six months, not updated with changes in condition, and not signed by licensed nurse. |
| Individual Service Plans (ISPs) were not completed within 10 days of admission, not reviewed by licensed nurse, and not updated every six months or with condition changes. |
| Facility driver lacked required transportation training and certificates for safe resident transport. |
| Medication Administration Records (MARs) for residents did not include both brand and generic names of medications. |
| Failed to convene team meeting prior to hospice admission and failed to update Individual Service Plan to include hospice coordination for a hospice resident. |
Report Facts
Residents on census: 61
Temporary license period: 120
Maximum consecutive temporary licenses: 2
Civil monetary penalty: 5000
Refund notice period: 7
Belongings claim period: 45
Admission agreement termination notice: 15
Admission agreement cost change notice: 30
Resident evaluation timeframe: 15
Resident evaluation review timeframe: 6
ISP completion timeframe: 10
ISP review timeframe: 6
Hospice training hours: 6
Hospice specific training hours: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Service Director | Provided census data and confirmed deficiencies related to admission agreements, pet vaccinations, transportation training, and medication records. | |
| Administrator | Confirmed failure to apply for amended license timely and lack of hospice team meeting documentation. | |
| Activities Director | Direct Care Staff (DCS #8) | Facility driver lacking required transportation training. |
Inspection Report
Original Licensing
Deficiencies: 0
Aug 8, 2018
Visit Reason
The inspection was conducted as an initial licensing survey for Elmcroft of Quintessence to determine compliance for temporary licensure.
Findings
No deficiencies were found during the inspection, and temporary licensure was recommended at this time.
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