Inspection Report Summary
The most recent inspection on January 27, 2025, found deficiencies related to admissions, resident evaluations, and individual service plans, including documentation and timely assessments. Earlier inspections showed a mix of issues, including staff qualification documentation, fire safety inspections, and maintenance of safe water temperatures, with some complaint investigations resulting in deficiencies while others were unsubstantiated. Main themes across reports included documentation and procedural compliance, fire safety inspections, and environmental safety such as hot water temperature and electrical outlet maintenance. Complaint investigations were mostly unsubstantiated except for the most recent one, which identified deficiencies tied to admission and care planning processes. The inspection history shows recurring challenges in administrative and safety documentation, with no clear pattern of overall improvement or decline.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
24 residents
Based on a January 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 4
Date: Jan 27, 2025
Visit Reason
A Complaint Survey was conducted at Sierra Vista by the New Mexico Health Care Authority to determine compliance with the New Mexico State Requirements for Assisted Living Facilities.
Complaint Details
The complaint intake numbers NM#73041 and another redacted number were investigated with deficiencies cited. The survey was conducted as a complaint investigation.
Findings
The survey found that the facility was not in compliance with participation requirements, citing deficiencies related to admissions, resident evaluation, and individual service plans, including failure to ensure proper documentation and timely assessments.
Deficiencies (4)
Failure to comply with admissions and discharge requirements including team approval and documentation.
Failure to complete resident evaluation within 15 days prior to admission.
Failure to develop and implement an individual service plan within 10 calendar days of admission.
Failure to revise individual service plan to include interventions for falls.
Report Facts
Census: 24
Days prior to admission for resident evaluation: 15
Falls sustained: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Cordova | Bureau Chief, Licensed Oversight Bureau, Division of Health Improvement | Signed the notice letter regarding the complaint survey and plan of correction. |
| Carol Andrade | Administrator | Facility administrator addressed in the notice letter. |
Inspection Report
Annual Inspection
Census: 20
Deficiencies: 5
Date: Aug 24, 2023
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to assess compliance with 7 NMAC 8.2, Regulations for Assisted Livings for Adults, including complaint investigations with no deficiencies cited.
Complaint Details
Complaint intake investigations were conducted with no deficiencies cited.
Findings
The facility was found deficient in staff qualifications related to Employee Abuse Registry clearance prior to hire, lack of vaccination documentation for pets, failure to ensure annual inspection of gas/fuel-fired heater, and failure to conduct monthly inspections of fire extinguishers. Other areas such as fire clearance and memory care unit requirements were also reviewed with some deficiencies noted.
Deficiencies (5)
Failed to ensure that Direct Care Staff had been cleared by the Employee Abuse Registry prior to hire.
Failed to maintain proper documentation that pets living in the facility had been vaccinated.
Failed to ensure that the facility's gas/fuel-fired heater was checked and tested annually by qualified personnel.
Failed to ensure that fire extinguishers were inspected monthly as recommended by the manufacturer.
Failed to ensure annual fire inspection from local fire prevention authority was obtained and documented.
Report Facts
Resident Census: 20
Civil monetary penalty: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Executive Director | Interviewed and confirmed issues with Employee Abuse Registry clearance and other findings | |
| Assistant Administrator | Interviewed and confirmed issues with gas/fuel-fired heater inspection and fire extinguisher inspections |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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 survey.
Inspection Report
Routine
Deficiencies: 0
Date: May 12, 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
Date: Apr 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 survey.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 8, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
The survey focused on COVID-19 infection prevention and control measures at the facility.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 31, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
The survey focused on COVID-19 infection prevention and control measures at the facility.
Inspection Report
Routine
Deficiencies: 0
Date: 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
Date: Oct 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
Complaint Investigation
Census: 19
Deficiencies: 5
Date: Aug 3, 2017
Visit Reason
The inspection was a Full-Onsite survey with 1 complaint completed for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities. The complaint intake NM#30105 was unsubstantiated but deficiencies were cited.
Complaint Details
Complaint Intake NM#30105 was unsubstantiated but deficiencies were cited.
Findings
The facility was found deficient in multiple areas including admission/discharge agreements lacking specific termination language, failure to monitor and document dishwasher temperatures, hot water temperatures exceeding safe limits, non-functional GFCI outlets near water sources, and failure to obtain an annual fire inspection which was four years past due.
Deficiencies (5)
Admission/Discharge Agreements for 4 residents did not state that the facility can terminate the agreement 'If' an appropriate placement has been found.
Dishwasher cleanliness, jets, and thermostatic controls were not monitored or documented; no monthly temperature logs maintained.
Hot water temperatures in resident areas exceeded the safe range of 95-110 degrees Fahrenheit, reaching up to 122.4 degrees F.
Electrical outlet (GFCI) near kitchen sink was not functioning properly and did not trip when tested.
Annual fire inspection by Local Fire Authority was not conducted and was four years past due.
Report Facts
Residents on census: 19
Admission/Discharge Agreements reviewed: 4
Dishwasher temperature logs: 0
Hot water temperature: 122.4
Hot water temperature: 120.2
Years past due for fire inspection: 4
Inspection Report
Routine
Deficiencies: 2
Date: Apr 8, 2009
Visit Reason
The inspection was conducted to review compliance with personnel training requirements and water safety standards at Sierra Vista Retirement Community.
Findings
The facility failed to ensure ongoing staff training for 6 of 8 employees and did not maintain hot water temperatures between 95 and 110 degrees Fahrenheit in resident-accessible areas, with specific sinks observed outside this range.
Deficiencies (2)
Failure to ensure ongoing training for 6 of 8 facility employees on required topics including Fire Safety, Safe Food Handling, Confidentiality of Records, Infection Control, Resident Rights, Reporting Requirements for Abuse, Neglect, and Exploitation, and Providing Quality Resident Care.
Failure to maintain hot water temperature accessible to residents between 95 and 110 degrees Fahrenheit, with multiple bathroom sinks observed outside this range.
Report Facts
Number of employees lacking ongoing training: 6
Number of employees reviewed for training documentation: 8
Date of last training documented: Jan 8, 2008
Hot water temperature minimum: 95
Hot water temperature maximum: 110
Observed hot water temperature readings: 64
Observed hot water temperature readings: 70
Observed hot water temperature readings: 90
Observed hot water temperature readings: 78
Observed hot water temperature readings: 70
Inspection Report
Life Safety
Census: 24
Capacity: 24
Deficiencies: 4
Date: Apr 8, 2009
Visit Reason
The inspection was conducted as an annual Life Safety Code survey for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in several areas related to building construction, maintenance of building and grounds, hazardous areas, and elements of the facility electrical system. Deficiencies included failure to provide accessibility for persons with disabilities, maintenance issues creating fire hazards, and improper labeling and maintenance of electrical breakers.
Deficiencies (4)
Facility failed to provide accessibility to persons with disabilities in accordance with New Mexico Building Code and the American Disabilities Act.
Facility failed to maintain hazardous areas and grounds in a safe, clean, and functioning environment.
Facility failed to maintain a hazardous area with 1-hour fire rating construction as required by NFPA 101 Life Safety Code.
Facility failed to install and maintain electrical systems and components properly, including labeling of breakers.
Report Facts
Licensed capacity: 24
Census: 24
Number of electrical panels: 3
Slope requirement for ramps: 12
Door clearance for wheelchair access: 34
Turning radius for wheelchair: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director | Acknowledged findings during exit conferences and provided statements regarding facility conditions. | |
| Maintenance Director | Responded to observations about furniture blocking access and maintenance issues. |
Inspection Report
Deficiencies: 8
Date: May 17, 2007
Visit Reason
The inspection was conducted to assess compliance with staff qualifications, admissions policies, caregiver screening, and training requirements at Sierra Vista Retirement Community.
Findings
The facility failed to ensure all direct care staff had required ongoing annual training, failed to convene required team meetings for residents needing care beyond facility capabilities, failed to notify licensing authority of admission/retention exceptions, failed to ensure timely and documented caregiver criminal history screenings, failed to check the Employee Abuse Registry for staff, and failed to provide required incident management training within mandated timeframes.
Deficiencies (8)
Failed to ensure 100% of direct care staff had ongoing annual training including Abuse, Neglect and Exploitation, First Aid, and Safe Food Handling.
Failed to convene a team meeting for a resident requiring care beyond facility capabilities and failed to include the Ombudsman in the team meeting.
Failed to notify the licensing authority within five days of admission/retention exceptions requiring nursing services.
Failed to have documentation that direct care staff had been cleared through the New Mexico Caregivers' Criminal History Screening Program.
Failed to timely submit required information to the New Mexico Caregivers' Criminal History Screening Program within 20 calendar days of employment.
Failed to maintain documentation that the Employee Abuse Registry was checked for staff prior to employment.
Failed to ensure a curriculum for training on abuse, neglect, and misappropriation of property was in place for all employees.
Failed to provide required training on abuse, neglect, and exploitation within required timeframes for all employees.
Report Facts
Residents requiring admission/retention exception: 1
Direct care staff files reviewed: 5
Staff files reviewed for Employee Abuse Registry check: 4
Direct care staff requiring criminal history screening: 1
Days for timely submission to CCHS: 20
Days to train new employees: 30
Days to train current employees: 90
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