Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Routine
Deficiencies: 0
Oct 23, 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
Aug 7, 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
Abbreviated Survey
Deficiencies: 0
Jul 20, 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
Apr 24, 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 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 16, 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
Feb 25, 2020
Visit Reason
The visit was a Revisit/Follow-up survey to verify compliance with state requirements for Assisted Living Facilities under 7 NMAC 8.2.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 02/25/20.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Oct 9, 2019
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to assess compliance with state regulations for Assisted Living facilities, triggered by complaint or allegation.
Findings
The facility was found deficient in multiple areas including admission agreements lacking refund provisions upon resident death, incomplete individual service plans missing expected goals and outcomes, improper medication storage and labeling, incomplete medication administration records, failure to maintain hot food at required temperatures, and failure to conduct monthly fire drills.
Complaint Details
The visit was complaint-related as indicated by the report stating it was a Full-Onsite/Complaint survey.
Deficiencies (6)
| Description |
|---|
| Admission/Discharge Agreements did not include a refund provision in case of death compliant with 7.8.2.20 and Senate Bill 0335-2013. |
| Individual Service Plans (ISPs) for residents lacked expected goals and outcomes of services. |
| Medications were not stored in locked compartments and were not separated by resident. |
| Medication Administration Records (MARs) lacked both brand/generic names and diagnosis or reason for medications for multiple residents. |
| Prepared hot food was not maintained at the required temperature of 140 degrees Fahrenheit; observed fish served at 131 degrees Fahrenheit. |
| Monthly fire drills were not conducted; only fire training discussions were documented without actual evacuation exercises. |
Report Facts
Residents reviewed for Admission/Discharge Agreements: 4
Residents reviewed for Individual Service Plans: 4
Resident census: 39
Medications missing brand/generic names: 20
Medications missing diagnosis/reason: 21
Medications missing brand/generic names: 12
Medications missing diagnosis/reason: 17
Medications missing brand/generic names: 12
Medications missing diagnosis/reason: 18
Medications missing brand/generic names: 9
Medications missing diagnosis/reason: 11
Observed hot food temperature: 131
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chief Operations Officer | Interviewed and confirmed deficiencies related to Admission/Discharge Agreements, ISPs, medication MARs, and hot food temperatures. | |
| Director of Operations | Interviewed and confirmed medication storage deficiencies and lack of actual fire drills. |
Inspection Report
Original Licensing
Deficiencies: 1
Nov 21, 2014
Visit Reason
An initial licensing survey was conducted to assess compliance with state requirements for assisted living facilities under 7 NMAC 8.2.
Findings
The facility was found deficient in staff training, specifically in first aid training for direct care staff. The facility committed to providing ongoing training and corrective actions to meet regulatory requirements.
Deficiencies (1)
| Description |
|---|
| Failure to provide first aid training to 6 of 6 direct care staff reviewed, which could lead to residents not receiving immediate first aid in an emergency. |
Report Facts
Direct care staff lacking first aid training: 6
Residents in facility: 39
Hours of supervised orientation: 16
Hours of annual education: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Smith | Administrator | Acknowledged lack of first aid training for direct care staff in interview |
Inspection Report
Life Safety
Deficiencies: 0
Jun 26, 2014
Visit Reason
A 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 of the New Mexico State Regulations governing Requirements Assisted Living Facilities For Adults 7.8.2 NMAC.
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