Inspection Reports for Sierra Springs Assisted Living
503 Los Lentes Rd NE # 2, Los Lunas, NM 87031, NM, 87031
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Inspection Report
Routine
Deficiencies: 0
Aug 19, 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
May 13, 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
Monitoring
Deficiencies: 0
Apr 17, 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 8, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
The survey focused on infection prevention and control measures related to COVID-19; no specific deficiencies or findings were detailed in the report.
Inspection Report
Monitoring
Deficiencies: 0
Apr 2, 2020
Visit Reason
Attempted to conduct an offsite surveillance on March 31, April 1 and April 2, 2020 related to COVID-19 infection prevention and control.
Findings
No response was received from the facility during the attempted offsite surveillance.
Inspection Report
Routine
Deficiencies: 0
Mar 19, 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
Aug 31, 2017
Visit Reason
The visit was a Revisit/Follow-up survey conducted to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited as a result of the Revisit/Follow-up survey. The facility was found to be in substantial compliance.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 23, 2017
Visit Reason
A Revisit/Follow-up survey was completed on 02/23/17 for survey dated 10/05/16 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during this follow-up survey.
Inspection Report
Follow-Up
Census: 14
Deficiencies: 7
Feb 23, 2017
Visit Reason
Revisit survey/follow-up survey completed to verify correction of previous deficiencies related to resident evaluations, individual service plans, medication administration, hazardous areas, fire safety, and other regulatory requirements.
Findings
The facility was found to have uncorrected deficiencies from a prior survey including incomplete resident evaluations and service plans, improper medication administration documentation, unsafe storage of oxygen cylinders, lack of annual inspections for gas furnace and fire safety systems, and failure to conduct semi-annual inspections of kitchen range hood fire suppression system.
Deficiencies (7)
| Description |
|---|
| Resident evaluations were not completed within 15 days prior to admission, not reviewed or updated every 6 months, and not signed or dated by licensed staff for 3 residents. |
| Individual Service Plans (ISP) were not reviewed, revised, or signed by licensed staff every 6 months for 3 residents. |
| Oxygen cylinder tanks were stored in a laundry room with combustibles and no 'oxygen in use' signs posted on resident rooms using oxygen. |
| Medication Administration Records (MAR) lacked signatures of staff assisting with medications and documentation of desired results or problems encountered with PRN medications for 1 resident. |
| Gas furnace heater had not been inspected annually; last inspection was on 09/01/2015. |
| Annual fire and life-safety inspection was last completed on 11/02/2015 and not conducted annually as required. |
| Kitchen range hood fire suppression system was not inspected semi-annually; last inspection was on 08/20/2015. |
Report Facts
Residents affected: 3
Oxygen cylinders: 32
Residents census: 14
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 2
Oct 5, 2016
Visit Reason
The inspection was conducted as a complaint survey triggered by complaint #NM00030063 to investigate compliance with state regulations for assisted living.
Findings
The facility failed to report incidents of unusual occurrences, including a bed bug infestation in June 2016, to the Licensing Authority within the required 24 hours and did not conduct or submit internal investigations within 5 business days. Additionally, the facility failed to ensure that fire extinguishers were inspected annually and monthly as required.
Complaint Details
One complaint (#NM00030063) was substantiated. The complaint involved failure to report and investigate incidents such as bed bug infestations and failure to maintain fire extinguisher inspections.
Deficiencies (2)
| Description |
|---|
| Failure to report incidents of unusual occurrence, including bed bug infestation, to the Licensing Authority within 24 hours and failure to conduct and submit internal investigations within 5 business days. |
| Failure to ensure that 5 of 5 fire extinguishers were inspected annually and monthly to ensure proper working order. |
Report Facts
Residents at risk: 12
Fire extinguishers: 5
Inspection date: Oct 5, 2016
Inspection Report
Annual Inspection
Deficiencies: 9
Aug 11, 2015
Visit Reason
The inspection was a full on-site survey completed on 08/11/15 for the New Mexico Requirements for Assisted Living for Adults, including complaint numbers #29703 and #29742.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, resident records, resident evaluations, medication administration, hazardous areas, fire safety, water temperature, and oxygen storage. Several deficiencies were noted with corrective actions planned or underway.
Complaint Details
Complaints NM #29703 and #29742 were part of the inspection trigger.
Deficiencies (9)
| Description |
|---|
| Administrator had not completed a state approved certification program for Assisted Living Administrators. |
| Facility failed to ensure caregivers were properly trained to perform a 2-person transfer for one resident, resulting in actual harm in the form of bruising, skin tears, and wounds. |
| Facility failed to maintain complete, organized, and accessible resident records for multiple residents. |
| Resident evaluations were not completed within required timeframes and were incomplete for sampled residents. |
| Facility failed to ensure medication administration records were accurate and complete, including missing physician orders and medication errors. |
| Facility failed to ensure proper storage and labeling of medications and oxygen cylinders. |
| Facility failed to conduct required fire inspections and fire drills as scheduled. |
| Facility failed to ensure hot water temperatures were maintained within safe limits. |
| Facility failed to ensure fire alarm system components, including strobe lights and reset keys, were properly maintained and inspected. |
Report Facts
Resident skin tears: 6
Fire drills: 1
Oxygen cylinders: 5
Hot water temperature: 120
Fire alarm inspection date: 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Johnson | Administrator | Named in findings related to lack of certification and oversight of staff training and compliance. |
| Jason Gonzales | Inspector | Signed inspection report and findings. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 17, 2013
Visit Reason
A complaint investigation was completed for intake NM 00029064 related to state requirements for Assisted Living.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 15, 2012
Visit Reason
A complaint investigation was completed for intake NM00028020 on 03/15/12 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake NM00028020 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Original Licensing
Deficiencies: 8
Mar 18, 2009
Visit Reason
The inspection was conducted as an original licensing survey for Sierra Springs Assisted Living to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies related to resident records, medication administration, resident assessments, individual service plans, custodial drug permit requirements, and employee abuse registry documentation. The facility failed to maintain accurate medication records, complete resident assessments, and properly document employee background checks.
Deficiencies (8)
| Description |
|---|
| Failed to list all currently ordered medications, document errors, and omissions on the Medication Administration Record (MAR) for 3 of 4 residents. |
| Failed to document a health condition and contradicted another health condition for 1 of 4 residents. |
| Failed to have descriptions of identified needs on the Individual Service Plan (ISP) for 1 of 4 residents. |
| Failed to include goals and outcomes on the Individual Service Plans (ISP's) for 4 of 4 residents. |
| Failed to have quarterly reviews by the consulting pharmacist. |
| Failed to maintain records of disposition of narcotics for 1 resident; narcotic shift change count forms had several blanks. |
| Failed to make inquiry to the Employee Abuse Registry (COR) before or on the first day of employment for 2 of 4 employees. |
| Failed to send fees and pertinent information to the Criminal History Screening program within 20 days of date of hire for 1 of 3 employees. |
Report Facts
Residents reviewed: 4
Employees reviewed: 4
Dates of narcotic shift change count forms missing entries: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 28, 2008
Visit Reason
The inspection was conducted as a complaint investigation for New Mexico Regulations Governing Adult Residential Care Facilities, based on complaint intake NM 26378.
Findings
No deficiencies were cited during the complaint investigation. The facility was found to be in compliance with all New Mexico Regulations Governing Adult Residential Care Facilities 7 NMAC 8.2.
Complaint Details
Complaint intake NM 26378 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 28, 2007
Visit Reason
The inspection was conducted as a complaint investigation from 9/27/07 to 9/28/07 for New Mexico Regulations Governing Adult Residential Care facilities, based on complaint intake NM25849 which was substantiated with deficiencies cited.
Findings
The facility failed to ensure that no medications were started or discontinued without a physician's order for 3 of 8 sampled residents, and the Medication Administration Record (MAR) documentation was inaccurate. Specific medication discrepancies and lack of physician orders were found for residents #1, #2, and #7, including incorrect dosages and continued administration of discontinued medications.
Complaint Details
Complaint intake NM25849 was investigated and substantiated with deficiencies cited related to medication administration and documentation.
Deficiencies (2)
| Description |
|---|
| Failure to ensure medications were not started or discontinued without a physician's order for 3 of 8 sampled residents. |
| Inaccurate Medication Administration Record (MAR) documentation for residents #1, #2, and #7. |
Report Facts
Sampled residents with medication issues: 3
Date of physician order: 2007
Inspection Report
Annual Inspection
Deficiencies: 10
Apr 26, 2007
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations for Sierra Springs Assisted Living, including admission policies, medication administration, hazardous areas, fire clearance, employee screening, and training requirements.
Findings
The facility was found deficient in several areas including failure to convene required team meetings for residents needing nursing services, incomplete medication administration records, hazardous areas not properly maintained, lack of current fire inspection reports, untimely submission of criminal history screening for staff, and missing training documentation for abuse, neglect, and exploitation reporting.
Deficiencies (10)
| Description |
|---|
| Failed to convene a team meeting for 1 of 12 residents requiring nursing services. |
| Failed to ensure New Mexico State Ombudsman was part of team meetings for admission/retention exceptions. |
| Failed to submit care plans to licensing authority for admission/retention exceptions for 1 of 12 residents. |
| Failed to ensure medications were properly transcribed from physician's orders into Medication Administration Record for 1 of 12 residents. |
| Failed to ensure hazardous areas were protected and free from obstruction, including boiler and furnace room. |
| Failed to keep a current fire inspection report on file for 2006 or 2007. |
| Failed to ensure timely submission of criminal history screening for 1 of 9 direct care staff. |
| Failed to maintain documentation that the Employee Abuse Registry database was checked prior to employment for 100% of direct care staff. |
| Failed to ensure required training documentation for abuse, neglect, and exploitation reporting for 100% of facility staff. |
| Failed to post required abuse, neglect, and exploitation posters conspicuously in the facility. |
Report Facts
Residents requiring nursing services: 12
Direct care staff: 9
Facility staff: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged problems during exit interviews and stated intent to correct deficiencies | |
| Staff #3 | Direct care staff member with missing fingerprint submission and criminal history screening |
Inspection Report
Routine
Deficiencies: 7
Sep 26, 2006
Visit Reason
The inspection was a routine regulatory survey of Sierra Springs Assisted Living to assess compliance with state regulations including staff qualifications, personnel policies, resident rights, medication management, and safety standards.
Findings
The facility was found deficient in multiple areas including failure to timely submit caregiver criminal history screenings, lack of ongoing annual staff training, unsafe resident mail retrieval practices, improperly secured oxygen tanks, malfunctioning call box system, and multiple medication administration errors including inaccurate Medication Administration Records and failure to follow physician orders.
Deficiencies (7)
| Description |
|---|
| Failed to submit caregiver criminal history screening information timely for 3 employees. |
| Failed to provide ongoing annual training/inservices for 8 of 11 employees. |
| Failed to ensure safety of residents crossing busy street to obtain mail. |
| Call box system volume was turned down and could not be heard by staff. |
| Oxygen tanks were not individually secured as required by NFPA 99. |
| Medication Administration Records (MAR) did not accurately reflect prescribed medications and PRN orders for multiple residents. |
| Facility failed to follow physician orders for prescription medications for several residents, including incorrect dosages and missing physician orders. |
Report Facts
Employees with untimely criminal history screening: 3
Employees lacking annual training: 8
Residents affected by medication discrepancies: 10
Oxygen tanks unsecured: 8
Residents crossing street for mail: 2
Inspection Report
Re-Inspection
Deficiencies: 3
Mar 9, 2005
Visit Reason
The visit was a revisit to verify correction of deficiencies cited in a prior survey dated 11/5/2004.
Findings
The facility failed to implement the plan of correction related to individual service plans and food management. Specifically, individual service plans were not developed or reviewed within fourteen days of admission for 13 of 15 sampled residents, and documentation was lacking. Additionally, the facility failed to ensure staff wore hair restraints during food preparation and serving, as required by regulations.
Deficiencies (3)
| Description |
|---|
| Failure to develop and implement individual service plans within fourteen days of admission for 13 of 15 sampled residents. |
| Failure to provide documentation of individual service plans with current dates of review or signatures for 9 of 10 residents. |
| Failure to wear hair restraints when preparing and serving food to 15 of 15 sampled residents. |
Report Facts
Residents with delayed individual service plans: 13
Residents lacking documentation of current individual service plan review: 9
Residents observed without hair restraints during food preparation: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator | Interviewed regarding individual service plan documentation and food management practices. | |
| Facility Cook | Observed not wearing hair net during food preparation and serving. | |
| Day Caregiver | Interviewed about kitchen inspections and hair restraint compliance. | |
| Registered Nurse | Referenced as reviewing individual service plans but not documenting dates within fourteen days of admission. |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Nov 5, 2004
Visit Reason
An unannounced abbreviated survey was conducted on 11/05/2004 based on New Mexico requirements for adult residential care facilities to assess compliance with resident assessments, individual service plans, and food management regulations.
Findings
The facility failed to provide documentation of current resident assessments for 5 of 10 residents and failed to provide documentation of individual service plans with current review dates or signatures for 9 of 10 residents. Additionally, the kitchen failed to date and label 2 out of 5 opened foods in the freezer and the kitchen cook was observed not wearing a hair covering while preparing food.
Deficiencies (4)
| Description |
|---|
| Failed to provide documentation regarding current resident assessments for 5 of 10 residents. |
| Failed to provide documentation of individual service plans with current dates of review or signatures for 9 of 10 residents. |
| Failed to date and label 2 out of 5 opened foods in the freezer. |
| Kitchen cook was not wearing a hair covering while preparing food. |
Report Facts
Residents lacking current assessments: 5
Residents lacking current individual service plan review or signature: 9
Opened foods not dated or labeled: 2
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