Deficiencies (last 10 years)
Deficiencies (over 10 years)
9.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
21 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving multiple residents, including verbal abuse by a Certified Nurse Aide and failure to timely report and investigate these allegations.
Complaint Details
The complaint investigation involved 5 to 6 residents with allegations of abuse and neglect. The facility substantiated verbal abuse by CNA #1 who was terminated. The facility failed to report incidents and investigation results to the State Agency within required timeframes.
Findings
The facility failed to protect residents from abuse, specifically verbal abuse by a Certified Nurse Aide who was terminated for the incident. Additionally, the facility failed to timely report allegations of abuse and neglect to the State Agency within required timeframes and failed to submit investigation summaries within five working days.
Deficiencies (3)
Failed to keep residents free from abuse; CNA verbally abused resident by pulling her arm and making fun of her financial situation.
Failed to timely report allegations of abuse and neglect to the State Agency within twenty-four hours for multiple residents.
Failed to report the results of all investigations to the State Survey Agency within five working days of an incident.
Report Facts
Residents reviewed for abuse: 5
Residents reviewed for abuse and neglect: 6
Working days late for investigation summary submission: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Named in verbal abuse finding and terminated due to abuse | |
| Certified Nurse Aide (CNA) #2 | Named in neglect allegations | |
| Administrator (ADM) | Confirmed termination of CNA #1 and failure to report incidents and investigations timely |
Inspection Report
Deficiencies: 1
Date: Sep 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with providing activities of daily living (ADL) assistance, specifically bathing and showering, to residents who require such care.
Findings
The facility failed to provide adequate ADL assistance for baths or showers to 3 residents reviewed, which is likely to affect their dignity and health. Documentation and interviews revealed residents did not receive showers as scheduled, with some refusing and others not being offered assistance for multiple days.
Deficiencies (1)
Failed to provide activities of daily living assistance for baths or showers for 3 residents reviewed for ADL care.
Report Facts
Residents reviewed for ADL care: 3
Showers missed or not documented: 6
Showers missed or not documented: 5
Showers missed or not documented: 7
Showers missed or not documented: 7
Showers missed or not documented: 5
Showers missed or not documented: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed expectation that shower schedule be followed and acknowledged it was not |
Inspection Report
Original Licensing
Census: 21
Deficiencies: 6
Date: 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)
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
Deficiencies: 1
Date: Feb 6, 2025
Visit Reason
The inspection was conducted following a complaint regarding neglect when staff failed to complete timely rounds, resulting in a resident (R #24) lying on the floor for approximately three hours after a fall.
Complaint Details
The complaint was substantiated based on record review, video evidence, and interviews confirming that resident R #24 was left on the floor for over three hours after a fall due to staff neglect in completing rounds.
Findings
The facility failed to prevent neglect for resident R #24, who was found lying on the floor for over three hours after a fall due to staff not completing required rounds. The facility implemented corrective actions including hourly rounding, staff reeducation, audits, and increased monitoring.
Deficiencies (1)
Failure to prevent neglect when staff failed to complete rounds timely, resulting in resident R #24 lying on the floor for approximately three hours after a fall.
Report Facts
Residents affected: 1
Time resident left on floor: 3
Date of fall: Jul 4, 2024
Date of daughter notification: Jul 5, 2024
Date of care plan: Jun 7, 2024
Date of order for hourly checks: Jul 31, 2024
Date of audits: Aug 2, 2024
Date of fall audit completion: Jul 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed and stated expectations for rounds and resident care |
| CNA #1 | Certified Nursing Assistant | Confirmed rounds are required to be completed hourly with resident R #24 |
Inspection Report
Routine
Census: 96
Deficiencies: 12
Date: Feb 6, 2025
Visit Reason
Routine inspection of Sunset Villa Healthcare to assess compliance with regulatory requirements including resident care, safety, infection control, medication management, and care planning.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, maintain a homelike environment, prevent neglect, develop accurate care plans, provide adequate hydration, properly label medications, implement infection control and antibiotic stewardship programs, and offer vaccinations.
Deficiencies (12)
Failed to ensure privacy for resident while dressing in her room.
Failed to maintain a comfortable and homelike environment by not repairing wall and blinds in resident's room.
Failed to prevent neglect when resident lay on floor for approximately three hours after a fall.
Failed to create accurate baseline care plans for residents, missing key health information and interventions.
Failed to develop and implement comprehensive, person-centered care plans for residents.
Failed to revise care plans timely to include pain medication management.
Failed to provide adequate assistance with activities of daily living, specifically dressing.
Failed to maintain adequate hydration for resident by not offering drinks or documenting fluid intake.
Failed to ensure medications were labeled with proper open and expiration dates.
Failed to develop and implement an ongoing infection prevention and control program.
Failed to implement a comprehensive antibiotic stewardship program.
Failed to offer COVID-19 vaccinations to eligible residents after education and document vaccination status.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 96
Residents affected: 45
Residents affected: 4
Fluid intake days below CMS minimum: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed medication labeling issues with throat spray bottles |
| Director of Nursing | DON | Provided multiple confirmations regarding care plan deficiencies, medication labeling, hydration, vaccination, and infection control program |
| Infection Preventionist | IP | Confirmed lack of ongoing infection control and antibiotic stewardship program documentation |
| Maintenance Director | MD | Confirmed need for repairs in resident's room |
| Certified Nursing Assistant #1 | CNA | Confirmed rounds are required hourly for resident #24 |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 4
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to create accurate baseline care plans, failure to update and implement comprehensive care plans, failure to prevent accidents and falls, and failure to secure medication carts.
Complaint Details
The complaint investigation found substantiated deficiencies including incomplete baseline care plans for residents #1 and #3, lack of current comprehensive care plan for resident #2, failure to prevent falls and injuries for residents #1 and #6, and unsecured medication carts posing risk to 19 residents.
Findings
The facility failed to create accurate baseline care plans within 48 hours of admission for some residents, failed to maintain current comprehensive care plans, failed to prevent falls and accidents for residents at risk, and failed to ensure medication carts were locked when unattended, potentially exposing residents to harm.
Deficiencies (4)
Failed to create an accurate baseline care plan within 48 hours of admission for 2 residents.
Failed to update and implement a comprehensive person-centered care plan for 1 resident.
Failed to prevent accidents and provide adequate supervision to prevent falls for 2 residents, resulting in actual harm.
Failed to ensure medication carts were locked while not in use, potentially affecting 19 residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 19
Fall risk score: 7
Fall risk score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in fall risk supervision and expectations for resident #1 |
| Director of Nursing | Director of Nursing | Confirmed expectations regarding fall risk supervision and medication cart security |
| Regional Clinical Consultant | Regional Clinical Consultant | Interviewed regarding incomplete baseline care plans and fall risk supervision |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Interviewed regarding incomplete baseline care plans and fall risk supervision |
| Regional Nurse | Regional Nurse | Interviewed regarding incomplete care plans |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding fall risk supervision practices |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding fall risk supervision practices |
| Hospice Registered Nurse | Hospice Registered Nurse | Interviewed regarding fall incident of resident #1 |
| Occupational Therapy Aide | Occupational Therapy Aide | Interviewed regarding fall incident of resident #6 and failure to use gait belt |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding fall incident of resident #6 and assessment after fall |
| Regional Corporate Therapy Consultant | Regional Corporate Therapy Consultant | Interviewed regarding failure to follow facility protocol for gait belt use |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely and appropriate treatment and care to a resident (R #1) who exhibited signs of a stroke and significant weakness, which resulted in delayed treatment and the resident's subsequent death.
Complaint Details
The complaint investigation focused on resident R #1 who reported stroke symptoms and showed significant weakness during transfer but was not adequately assessed or treated in a timely manner. Staff failed to notify the physician or complete change of condition documentation. The resident became unresponsive, hypoxic, and was later transferred to the hospital where she expired. The investigation also included resident R #5 who eloped from the facility due to lack of an operational wander guard system at the time.
Findings
The facility failed to identify and adequately assess a change in condition for resident R #1, who reported stroke symptoms and demonstrated significant weakness during transfer. Staff did not notify the physician or complete required documentation, resulting in delayed emergency response and the resident's death. Additionally, the facility failed to provide adequate supervision to prevent elopement for resident R #5, who was found outside the facility without proper monitoring prior to installation of a wander guard system.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders and resident’s preferences, resulting in delayed treatment for resident R #1 who exhibited stroke symptoms and weakness.
Failure to ensure adequate supervision to prevent elopement for resident R #5, who was found outside the facility without proper monitoring.
Report Facts
Blood Pressure: 203
Blood Pressure: 156
Pulse Oximetry: 65
Weight: 244
Blood Glucose: 95
Wander Guard installation date: Sep 28, 2023
Elopement Risk Score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in relation to failure to assess resident R #1's weakness and delayed emergency response |
| CNA #1 | Certified Nurse Aide | Named in relation to observations of resident R #1's condition and transfer difficulties |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for change of condition documentation for resident R #1 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding staff responsibilities for resident R #1's hospital evaluation and change in condition |
| Physical Therapy Director | Physical Therapy Director | Interviewed regarding therapy sessions with resident R #1 |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding installation of wander guard system |
Inspection Report
Routine
Census: 49
Deficiencies: 23
Date: Mar 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to promote resident choice, inadequate resident council activities, unsafe environment due to blocked handrails, missed medical appointments due to transportation issues, failure to update care plans, failure to provide restorative therapy devices, inadequate assistance with activities of daily living such as bathing, failure to provide adequate behavioral health care and psychiatric services, failure to monitor psychotropic medication dose reductions, failure to maintain confidentiality of resident information, failure to provide required staff training, and failure to maintain food safety and medication storage standards.
Deficiencies (23)
Failed to promote residents' choices when staff failed to ensure medical appointments were not missed and residents were taken outdoors per their preference.
Failed to assist or provide opportunity for residents to organize a resident council.
Failed to provide a safe, comfortable, and homelike environment due to blocked handrails and unclean resident rooms.
Failed to allow a resident to return to the facility after hospitalization and did not provide discharge notice or evaluation.
Failed to develop and revise complete care plans timely for residents, including updating for medication use and falls.
Failed to schedule MRI appointments per physician orders resulting in untreated pain.
Failed to provide restorative physical therapy devices as ordered.
Failed to provide adequate assistance with activities of daily living including offering baths/showers and documenting refusals.
Failed to provide ongoing activities for residents who are bed bound or stay in their rooms.
Failed to have a qualified activities professional direct the activity program.
Failed to ensure a resident's hearing aids were functional and scheduled for repair or replacement.
Failed to effectively manage pain for a resident, including failure to assess pain, provide treatment, and schedule ordered diagnostic testing.
Failed to ensure sufficient nursing staff to meet resident needs, resulting in missed baths/showers.
Failed to provide necessary behavioral health care and services including psychiatric referrals and talk therapy.
Failed to implement gradual dose reductions for psychotropic medications as recommended.
Failed to provide or obtain routine dental services for a resident.
Failed to ensure medications and medical supplies were not expired.
Failed to maintain confidentiality of resident medical records, leaving protected health information visible.
Failed to offer COVID-19 vaccine to a resident and document consent.
Failed to ensure certified nurse aides received required training on abuse, neglect, exploitation, and dementia care.
Failed to ensure functioning call light system in resident bathroom.
Failed to provide special eating equipment as ordered for a resident.
Failed to ensure food was stored, prepared, distributed, and served according to professional standards.
Report Facts
Residents: 49
Baths or showers offered: 6
Baths or showers offered: 7
Baths or showers offered: 1
Baths or showers offered: 0
Pain scale rating: 10
Pain scale rating: 9
Pain scale rating: 8
Pain scale rating: 7
Pain scale rating: 6
Pain scale rating: 5
Pain medication administration: 30
Pain medication administration: 30
Pain medication administration: 31
Pain medication administration: 29
Pain medication administration: 5
Staff worked shifts: 15
Staff worked shifts: 2
Staff worked shifts: 4
Staff worked shifts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Interviewed regarding resident choice, resident council, and activity program |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including resident choice, care plans, pain management, psychiatric services, staffing, and training |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding resident baths/showers, hearing aids, and pain management |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding resident baths/showers and pain reporting |
| Maintenance Director | Maintenance Director | Interviewed regarding transportation and blocked handrails |
| Regional Clinical Consultant | Regional Clinical Consultant | Interviewed regarding staff training and activity program |
| Social Worker | Social Worker | Interviewed regarding psychiatric services and resident depression |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Interviewed regarding psychiatric services and talk therapy |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding resident pain and depression |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding resident depression and documentation |
| Regional Manager | Regional Manager | Interviewed regarding activity program staffing |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and kitchen cleanliness |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding hearing aids and resident baths/showers |
| Medical Records | Medical Records | Interviewed regarding hearing aids appointment scheduling |
| Restorative Certified Nursing Assistant | Restorative Certified Nursing Assistant | Interviewed regarding therapy device application |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding therapy device application and activity program |
| Maintenance Manager | Maintenance Manager | Interviewed regarding call light system |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Date: Dec 17, 2023
Visit Reason
The inspection was conducted as a Full-Onsite/Complaint survey to investigate two complaint intakes related to the facility.
Complaint Details
Two complaint intakes were investigated with no deficiencies cited.
Findings
No deficiencies were cited during the Full-Onsite/Complaint survey or the investigation of the two complaint intakes.
Inspection Report
Routine
Census: 42
Deficiencies: 13
Date: Feb 2, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, environment, medication management, staffing, food safety, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, maintain a safe and homelike environment, develop and distribute baseline care plans, provide comprehensive care plans, monitor pressure ulcers, ensure RN coverage, post staffing information, conduct monthly pharmacist drug regimen reviews, safely store medications, properly store and label food, safeguard resident medical records, maintain a working call system, and hold required QAPI meetings with all necessary members.
Deficiencies (13)
Failed to provide reasonable accommodations of resident needs and preferences by not positioning furniture to allow wheelchair access for resident #22.
Failed to maintain a safe, clean, comfortable, and homelike environment including rusted shower room, unsecured ladder, dust and clutter in common areas, and unlocked oxygen concentrator storage room.
Failed to provide and distribute baseline care plan summaries to residents or their representatives for 6 residents reviewed.
Failed to develop a comprehensive care plan including diabetic retinopathy eye injections for resident #8.
Failed to provide appropriate pressure ulcer care and monitor progress for resident #5 with a stage 3 pressure ulcer.
Failed to provide services of a Registered Nurse for at least 8 consecutive hours a day on 01/22/23.
Failed to post nurse staffing information daily, update at beginning of each shift, and retain staffing sheets for 18 months.
Failed to ensure consultant pharmacist performed monthly drug regimen reviews for residents #5, 15, and 29; missing June 2022 review.
Failed to ensure medications were stored safely; carded medications stored in an open box in the assistant director of nurses office.
Failed to store and label food properly in refrigerators and dry storage; issues with uncovered food, undated items, broken dishwasher gauge, and incomplete cleaning logs.
Failed to ensure accurate diagnosis for medication administration; medication Ezetimibe misdiagnosed for cough instead of hyperlipidemia for resident #22.
Failed to have required minimum members present for Quality Assessment and Assurance meetings for 1st and 4th quarters of 2022.
Failed to maintain a working call system in resident #20's bathroom; call bell did not activate audible or visual alarms and required unplugging to work.
Report Facts
Residents reviewed for homelike environment: 42
Residents reviewed for baseline care plans: 6
Residents reviewed for pressure ulcers: 3
Residents reviewed for unnecessary medications: 3
Residents affected by call system deficiency: 1
Residents affected by medication misdiagnosis: 1
Residents affected by QAPI meeting deficiency: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding diabetic retinopathy care plan and pressure ulcer treatment for resident #8 and #5 |
| Director of Nursing | DON | Interviewed regarding baseline care plan distribution, RN coverage, staffing sheets, and missing pharmacy review |
| Social Services Director | SSD | Interviewed regarding baseline care plan distribution |
| Maintenance Director | Maintenance Director | Interviewed regarding facility maintenance issues including rust, ladder, and oxygen storage room |
| Licensed Practical Nurse #2 | LPN | Observed and confirmed non-working call bell for resident #20 |
| Certified Nurse Assistant #2 | CNA | Observed and confirmed non-working call bell for resident #20 |
| Corporate Nurse Consultant | Nurse Consultant | Interviewed regarding missing pharmacy review paperwork |
| Dietary Manager | DM | Interviewed regarding food storage and dishwasher issues |
| Repairman | Repairman | Interviewed regarding dishwasher gauge malfunction |
| Administrator | Administrator | Interviewed regarding staffing sheets retention, dishwasher issues, and QAPI meetings |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication misdiagnosis for resident #22 |
| Nurse Practitioner | NP | Interviewed regarding pressure ulcer treatment for resident #5 |
| Assistant Director of Nursing | ADON | Interviewed regarding unsafe medication storage in open box |
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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
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
Complaint Investigation
Census: 23
Deficiencies: 9
Date: 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.
Complaint Details
Complaint intake NM00037488 was unsubstantiated with no deficiencies cited.
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.
Deficiencies (9)
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
Date: 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
Date: 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)
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
Date: 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.
Complaint Details
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.
Deficiencies (7)
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
Date: 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
Date: 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)
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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