Inspection Report
Re-Inspection
Census: 75
Deficiencies: 6
Dec 12, 2023
Visit Reason
Revisit survey completed for state requirements of NMAC 7.8.2, Regulations for Assisted Living Facilities for Adults to verify correction of previous deficiencies.
Findings
The facility was found to have uncorrected deficiencies related to staff qualifications, wound care, individual service plans, incident reporting, resident rights, nutrition, and food safety. Deficiencies included inadequate training and experience of direct care staff in wound care, failure to update individual service plans to reflect significant health changes, failure to report incidents timely, and failure to maintain proper food safety and sanitation practices.
Deficiencies (6)
| Description |
|---|
| Direct Care Staff lacked adequate, relevant training or experience for wound care. |
| Individual Service Plans (ISP) were not updated to reflect significant health changes for residents. |
| Failure to report incidents of possible neglect or abuse to Licensing Authority within required timeframes. |
| Resident rights were not fully protected including rights to voice grievances and participate in care planning. |
| Nutrition services failed to meet requirements for meal service and dietary needs. |
| Food safety and sanitation deficiencies including improper storage and disposal of food and trash. |
Report Facts
Census: 75
Deficiency count: 6
Random chart review percentage: 10
Random chart review percentage: 5
Incident reporting timeframe: 24
Investigation report submission timeframe: 5
Meal service requirement: 3
Meal service interval: 16
Food storage temperature: 41
Food storage temperature: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Womack | Executive Director | Signed the report on page 1 |
| DCS #5 | Direct Care Staff | Named in wound care deficiencies and incident reporting |
| RN #2 | Registered Nurse | Provided wound care and involved in incident documentation |
| RN #3 | Registered Nurse | Involved in wound care and incident documentation |
| AL Manager | Assisted Living Manager | Interviewed regarding incident reporting and wound care |
| DON | Director of Nursing | Responsible for long-term quality measures and wound care oversight |
| ED | Executive Director | Responsible for reporting and oversight of quality measures |
| Director of Food and Beverage | Responsible for food safety and kitchen inspections |
Inspection Report
Abbreviated Survey
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 survey.
Inspection Report
Routine
Deficiencies: 0
Jul 22, 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
Complaint Investigation
Deficiencies: 0
Jun 3, 2020
Visit Reason
The inspection was conducted as an offsite complaint survey related to Complaint #NM44682 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
No deficiencies were cited during the offsite complaint survey, and the complaint was found to be unsubstantiated without deficiencies cited.
Complaint Details
Complaint #NM44682 was unsubstantiated without deficiencies cited.
Inspection Report
Routine
Deficiencies: 0
Apr 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
Mar 27, 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 12, 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
Re-Inspection
Deficiencies: 0
Jun 30, 2015
Visit Reason
The revisit survey was completed to verify correction of previously identified deficiencies for the State of New Mexico Requirements for Assisted Living facilities for adults.
Findings
The deficiencies identified in the prior survey were cleared during the revisit survey, and the facility was found to be in compliance with state regulations.
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 3
Dec 11, 2014
Visit Reason
An initial survey was completed on 12/11/14 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility failed to ensure that staff employees had 12 hours of annual in-service training including first aid, safe food handling, confidentiality, infection control, and resident rights. Additionally, the facility failed to submit required applications, fingerprint cards, and fees for caregiver criminal history screening, and failed to make inquiries to the Employee Abuse Registry for several direct care staff.
Deficiencies (3)
| Description |
|---|
| Staff failed to complete required 12 hours of annual in-service training including first aid, confidentiality, infection control, and resident rights. |
| Facility failed to submit applications, fingerprint cards, and fees to the Caregiver Criminal History Screening Program within required timeframes. |
| Facility failed to inquire to the Employee Abuse Registry for multiple direct care staff members. |
Report Facts
Number of residents: 72
Number of caregivers reviewed: 9
Number of caregivers lacking required training: 3
Hours of required annual training: 12
Inspection Report
Original Licensing
Deficiencies: 0
Jun 20, 2013
Visit Reason
An initial Life Safety Code survey was conducted at the Palmilla Senior Living Assisted Living Facility at the provider's request to assess compliance and determine occupancy recommendation.
Findings
The facility was initially not recommended for occupancy on June 20, 2013. After receipt of correspondence and photographs addressing survey findings on June 26, 2013, the facility was found to be in substantial compliance with New Mexico State Regulations and occupancy was recommended.
Inspection Report
Original Licensing
Deficiencies: 0
Jun 20, 2013
Visit Reason
An initial Life Safety Code survey was conducted at the Palmilla Senior Living Assisted Living Facility at the provider's request to assess compliance and occupancy recommendation.
Findings
The facility was initially not recommended for occupancy on June 20, 2013, but after receipt of correspondence and photographs addressing survey findings, the facility was found to be in substantial compliance with New Mexico State Regulations and occupancy was recommended.
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