Inspection Report
Original Licensing
Census: 21
Deficiencies: 6
Aug 20, 2025
Visit Reason
The inspection was a compliant initial survey conducted to assess compliance with New Mexico regulations for Assisted Living facilities for Adults.
Findings
The facility was found deficient in multiple areas including staff qualifications, resident records maintenance, medication storage and labeling, nutrition and food safety, housekeeping, and fire extinguisher inspections.
Deficiencies (6)
| Description |
|---|
| Failure to ensure kitchen staff had clearance from the Employee Abuse Registry prior to hire and timely submission of fingerprints to the Caregivers Criminal History Screening Program. |
| Failure to maintain complete resident records including initial facility evaluation and care plans. |
| Failure to store all residents' medications in locked compartments or locked rooms, including medication refrigerators. |
| Failure to label food items with dates to determine expiration, resulting in undated and potentially expired food items in kitchen and refrigerator. |
| Failure to store poisonous or flammable chemicals in secured areas away from residential areas. |
| Failure to inspect fire extinguishers monthly as recommended by the manufacturer, with last inspections dated 06/07/2025. |
Report Facts
Resident census: 21
Fingerprints submission timeframe: 20
Fine amount: 5000
Fire extinguisher inspection interval: 30
Temperature range: 35
Temperature range: 41
Hot food temperature: 140
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Dec 17, 2023
Visit Reason
The inspection was conducted as a Full-Onsite/Complaint survey to investigate two complaint intakes related to the facility.
Findings
No deficiencies were cited during the Full-Onsite/Complaint survey or the investigation of the two complaint intakes.
Complaint Details
Two complaint intakes were investigated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 26, 2021
Visit Reason
Offsite Revisit/Follow-up survey to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited and the facility was found to be in compliance for this survey.
Inspection Report
Routine
Deficiencies: 0
Apr 21, 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 6, 2020
Visit Reason
An offsite survey was completed for infection control related to COVID-19.
Findings
No deficiencies were cited during the infection control survey.
Inspection Report
Monitoring
Deficiencies: 0
Apr 2, 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
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
Complaint Investigation
Census: 23
Deficiencies: 9
Sep 11, 2019
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to assess compliance with state regulations for Assisted Living Facilities, including investigation of complaint intake NM00037488 which was unsubstantiated.
Findings
The facility was found deficient in multiple areas including staff training, incident reporting, resident rights, medication administration, nutrition, laundry services, hazardous area protections, automatic fire protection system maintenance, and hospice care training. Several deficiencies were repeat findings from prior surveys.
Complaint Details
Complaint intake NM00037488 was unsubstantiated with no deficiencies cited.
Deficiencies (9)
| Description |
|---|
| Direct Care Staff failed to receive all required annual trainings on confidentiality, abuse reporting, and implementation of resident ISPs. |
| Facility failed to report an incident of abuse to the Licensing Authority within required timeframes. |
| Residents were exposed to unsafe living conditions including unlocked cabinets with harmful chemicals and use of physical restraints. |
| Medication Administration Records (MAR) lacked required information including PCP name, diagnosis, brand/generic names, start dates, and physician orders. |
| Facility failed to maintain close-fitting lids on refuse containers in the kitchen. |
| Laundry and cleaning supplies were stored in an unsecured cabinet accessible to residents. |
| Laundry room door self-closing device was defective, leaving the door open and compromising fire safety. |
| Fire sprinkler escutcheons were missing or displaced in multiple resident rooms, impairing sprinkler function. |
| Direct Care Staff failed to receive the required six hours of annual palliative/hospice care training including one hour specific to resident ISPs. |
Report Facts
Number of residents at risk: 23
Number of hospice residents: 4
Hours of required staff training: 6
Hours of training received: 1.17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #1 | Direct Care Staff | Named in deficiency for lack of required annual training and hospice care training. |
| DCS #2 | Direct Care Staff | Named in deficiency for lack of required annual training and hospice care training. |
| DCS #3 | Direct Care Staff | Named in deficiency for lack of required annual training and hospice care training. |
| Administrator | Confirmed deficiencies during interviews regarding training, incident reporting, and fire safety. | |
| Manager | Confirmed missing information on Medication Administration Records. |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 21, 2017
Visit Reason
A Revisit/Follow-up survey was completed on 03/21/17 for surveys dated 08/19/15 and 01/05/17 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
There were no deficiencies cited and the facility was found to be in substantial compliance.
Inspection Report
Follow-Up
Deficiencies: 2
Jan 5, 2017
Visit Reason
The visit was a Revisit/Follow up survey to determine compliance with state requirements for Assisted Living facilities, specifically to verify correction of previously cited deficiencies.
Findings
The facility failed to provide full access to requested documents including resident lists, staff records, fire drill records, and training documentation, denying the licensing authority the ability to inspect care and operations. Additionally, the facility failed to ensure that two residents had admission evaluations completed prior to their admission, a repeat deficiency from a prior survey.
Deficiencies (2)
| Description |
|---|
| Failure to provide full access to requested documents such as resident lists, staff records, fire drill records, and training documentation. |
| Failure to ensure residents had admission evaluations completed prior to admission, affecting 2 residents. |
Report Facts
Residents with delayed admission evaluations: 2
Inspection Report
Complaint Investigation
Deficiencies: 7
Aug 19, 2015
Visit Reason
A complaint investigation for intake NM00029719 and an On-site/Monitoring survey were completed on 08/19/15 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living. The complaint was unsubstantiated.
Findings
Deficiencies were cited as a result of the Full-Onsite/Monitoring survey. The facility failed to have a Resident evaluation or Individual Service Plan for one resident, failed to keep medications including narcotics secured, failed to maintain accurate Medication Administration Records, failed to ensure cooks and food handlers wore hair nets or caps, failed to maintain sprinkler heads, and failed to conduct and document monthly fire drills among other deficiencies.
Complaint Details
The complaint was unsubstantiated.
Deficiencies (7)
| Description |
|---|
| Facility failed to have a Resident evaluation or Individual Service Plan for one resident. |
| Facility failed to keep medications including narcotics secured in locked compartments. |
| Facility failed to maintain accurate Medication Administration Records for residents. |
| Facility failed to ensure cooks and food handlers wore hair nets or caps. |
| Facility failed to maintain sprinkler heads throughout the building. |
| Facility failed to conduct and document monthly fire drills for all residents. |
| Facility failed to maintain required documentation for employee abuse registry and criminal history screening. |
Report Facts
Residents reviewed: 5
Caregivers observed: 56
Residents in facility: 19
Fire drills documented: 0
Staff files reviewed: 17
Sprinkler heads: 9
Inspection Report
Original Licensing
Deficiencies: 0
Oct 1, 2008
Visit Reason
This was the first original licensing inspection of the facility Sunset Vista in Silver City, NM.
Findings
The facility was found to be in compliance with all New Mexico Regulations Governing Adult Residential Care Facilities 7 NMAC 8.2, with no deficiencies noted.
Inspection Report
Annual Inspection
Deficiencies: 8
Nov 2, 2006
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations, including review of caregiver criminal history screening, resident records, medication administration, nutrition, heating and ventilation systems, and other facility requirements.
Findings
The facility was found deficient in several areas including failure to have documentation of caregiver criminal history screening for one staff member, lack of staff signatures and dates on residents' daily progress notes, missing names of staff administering medications on medication administration records, failure to meet weekly meal menu requirements, and failure to properly screen windows for ventilation in residents' rooms. Corrective actions and plans were documented with completion dates.
Deficiencies (8)
| Description |
|---|
| Facility failed to have documentation of caregivers criminal history screening clearance letters for 1 of 3 staff (S22). |
| Facility failed to have 'conditional supervised employment' for 1 staff (S22) with no CCHS letter; staff worked unsupervised. |
| Facility failed to have staff signatures on residents' daily progress notes for 3 of 3 residents (R1, R2, R3). |
| Facility failed to have dates on residents' daily progress notes for 3 of 3 residents (R1, R2, R3). |
| Facility failed to have names of staff administering medications on the Medication Administration Record (MAR) for 3 of 3 residents (R1, R2, R3). |
| Facility failed to meet requirements for the weekly meal menu; snacks were not included. |
| Facility failed to properly screen windows used for ventilation in 4 of 8 residents' rooms; window screens had holes and needed replacement. |
| Facility failed to have annual inspections of the fuel-fire heating system by qualified personnel. |
Report Facts
Residents with unsigned daily progress notes: 3
Residents with undated daily progress notes: 3
Residents with missing staff names on MAR: 3
Residents' rooms with window screen deficiencies: 4
Inspection completion date: Nov 2, 2006
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Miranda | Supervisor / Facility Manager | Named in corrective action plan related to fingerprint cards and medication administration record review |
| Elizabeth Sircy | Facility Operator | Named as contracting with J & S Plumbing and Heating for heating system inspection and maintenance |
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