Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 6
Jun 27, 2025
Visit Reason
Complaint survey completed on 06/27/2025 for state requirements of NMAC 8.370.14, Regulations for Assisted Living Facilities for Adults, investigating complaint intake NM.
Findings
Deficiencies were cited related to staff qualifications, resident records maintenance, reporting of incidents, custodial drug permits, medication administration, and housekeeping services. Issues included failure to provide employee background clearance prior to hire, missing resident medication records, failure to report incidents timely to licensing authority, medication labeling errors, incomplete medication administration records, and unsecured hazardous chemicals accessible to residents.
Complaint Details
Complaint Intake NM was investigated and deficiencies were cited.
Deficiencies (6)
| Description |
|---|
| Failed to provide employee background clearance documentation by the Employee Abuse Registry prior to hire for 1 of 6 staff. |
| Failed to maintain non-current resident records against loss, destruction, and unauthorized use for at least five years and readily available within 24 hours. |
| Failed to report incidents to the licensing authority complaint hotline within 24 hours and submit investigation report within five business days for 1 resident. |
| Failed to ensure medications were labeled with the correct last name for 1 resident. |
| Failed to maintain complete medication administration records (MAR) and failed to take blood pressure as ordered for 1 resident. |
| Failed to store cleaning supplies and hazardous chemicals in secured areas, accessible to residents. |
Report Facts
Resident Census: 75
Number of staff files reviewed: 6
Number of residents with medication record issues: 4
Number of residents with medication labeling issues: 1
Number of residents with incident reporting issues: 1
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Apr 22, 2024
Visit Reason
The inspection was a full onsite complaint survey conducted to investigate two complaint intakes, both of which were investigated with no deficiencies cited.
Findings
Two main deficiencies were cited: failure to ensure monthly inspection and maintenance of fire extinguishers, and failure to document monthly fire drills including number of staff participating and evacuation times. These deficiencies could place 76 residents and staff at risk of harm in case of fire.
Complaint Details
Two complaint intakes were investigated with no deficiencies cited related to the complaints.
Deficiencies (2)
| Description |
|---|
| Fire extinguishers were not inspected monthly as recommended by the manufacturer, with some extinguishers last inspected in 02/2024 despite observations in April 2024. |
| Monthly fire drills were not properly documented, missing number of staff participating and total evacuation time in minutes. |
Report Facts
Census: 76
Dates of fire drill logs missing documentation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed fire extinguishers had not been inspected monthly and fire drill logs lacked documentation | |
| Assistant Executive Director | Confirmed fire drill logs did not have required documentation | |
| Supervisor-Administrator | Provided census information |
Inspection Report
Follow-Up
Deficiencies: 1
Sep 30, 2022
Visit Reason
The visit was a Follow-up/Revisit survey conducted on 09/30/22 for the state requirements of 7 NMAC 8.2 Regulations for Assisted Living for Adults.
Findings
The facility failed to ensure that Individual Service Plans (ISPs) for 7 of 8 residents reviewed were properly reviewed, revised, and included all required elements such as description of needs, services provided, who provides them, goals, frequency, and crisis prevention plans. The Administrator confirmed these findings during the survey.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Individual Service Plans were reviewed and revised as needed by licensed staff and included all required elements for 7 of 8 residents reviewed. |
Report Facts
Residents with deficient ISPs: 7
Residents reviewed: 8
Date of survey completion: Sep 30, 2022
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 7
Nov 12, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on multiple substantiated and unsubstantiated complaints regarding compliance with state regulations for Assisted Living Facilities.
Findings
The facility was found deficient in multiple areas including Individual Service Plans, Reporting of Incidents, Resident Rights, Medication Records Privacy, Custodial Drug Permits, Oxygen Storage, Medication Destruction, and Housekeeping Services. Several complaints were substantiated with deficiencies cited, while others were unsubstantiated.
Complaint Details
Multiple complaints were investigated: NM46541, NM46570, NM46839, NM44434, NM47155, and NM45399 were substantiated with deficiencies cited. Complaints NM44804, NM46840, and NM44746 were unsubstantiated with no deficiencies cited.
Deficiencies (7)
| Description |
|---|
| Failure to ensure Individual Service Plans included a description of identified needs as noted in the resident evaluation. |
| Failure to report incidents of possible abuse, neglect, or exploitation to the Licensing Authority within required timeframes. |
| Failure to protect resident rights including freedom from financial abuse, isolation, and confidentiality of medical records. |
| Medication carts with unsecured computers and resident information were observed unattended. |
| Failure to comply with custodial drug permit requirements including medication storage, labeling, and destruction. |
| Oxygen tanks were not stored securely and unsecured oxygen cylinders were found in resident rooms. |
| Failure to maintain resident bedrooms clean and sanitary, with resident rooms being dirty, dusty, and uncleaned due to lack of housekeeping staff. |
Report Facts
Residents at risk: 40
Residents reviewed for ISP compliance: 14
Residents with incident report review: 3
Residents on census list: 40
Unsecured oxygen cylinders observed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johnnie Mullen | Executive Director | Interviewed regarding Individual Service Plans, incident reporting, resident rights, and housekeeping deficiencies. |
| Tony Abeyta | Physical Plant Manager | Mentioned in attendance at inspection. |
| Michele McDaniel | Regional Nurse | Presented the inspection report and involved in re-inservicing staff on various compliance topics. |
Inspection Report
Follow-Up
Deficiencies: 1
May 6, 2021
Visit Reason
The visit was a Revisit/Follow-up survey to assess compliance with state requirements for Assisted Living Facilities, specifically related to memory care units and dementia care.
Findings
The facility failed to ensure that Direct Care Staff completed the required minimum of twelve hours of annual Dementia/Alzheimer's training. This deficiency could place 11 memory care residents diagnosed with dementia at risk of not receiving appropriate care.
Deficiencies (1)
| Description |
|---|
| Direct Care Staff did not complete the required minimum twelve hours of annual Dementia/Alzheimer's training. |
Report Facts
Memory Care Residents at risk: 11
Required training hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #2 | Direct Care Staff | Employee file showed no documentation of required Dementia/Alzheimer's training. |
| DCS #3 | Direct Care Staff | Employee file showed no documentation of required Dementia/Alzheimer's training. |
Inspection Report
Follow-Up
Census: 27
Deficiencies: 4
Dec 3, 2020
Visit Reason
The visit was a Revisit/Follow-up survey to verify correction of previously cited deficiencies related to staff training, admissions and discharge agreements, custodial drug permits, and memory care unit requirements.
Findings
The facility was found deficient in ensuring direct care staff received required annual trainings, including dementia/Alzheimer's training, and failed to include required refund policies in admission agreements. Additionally, prescribed medications were not always available for residents, and memory care unit staffing and training requirements were not fully met.
Deficiencies (4)
| Description |
|---|
| Failed to ensure Direct Care Staff received required annual trainings including proper implementation of resident Individual Service Plans. |
| Admission/Discharge agreements for residents did not include the refund policy for death as required by Senate Bill 0335-2013. |
| Prescribed medications were not readily available for one resident, resulting in missed or unavailable doses. |
| Direct Care Staff did not receive the required twelve (12) hours of annual Dementia/Alzheimer's training for memory care residents. |
Report Facts
Residents present: 27
Direct Care Staff annual dementia training hours: 3.25
Memory Care residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #4 | Direct Care Staff | Named in findings for lack of required annual trainings and dementia/Alzheimer's training |
| Executive Director | Confirmed deficiencies related to staff training and admission agreements during interviews |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 18, 2020
Visit Reason
Offsite Revisit/Follow-up survey completed to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the offsite Revisit/Follow-up survey. The facility was found to be in compliance.
Inspection Report
Routine
Deficiencies: 0
Aug 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 COVID-19 infection prevention and control survey.
Inspection Report
Routine
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
Jun 23, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection and prevention control.
Findings
No deficiencies were cited during the COVID-19 infection and prevention control survey.
Inspection Report
Monitoring
Deficiencies: 0
Apr 27, 2020
Visit Reason
An offsite surveillance survey was conducted for COVID-19 infection and prevention control.
Findings
No deficiencies were cited during the COVID-19 infection and prevention control surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Apr 16, 2020
Visit Reason
An offsite surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
The facility was found to be in compliance with COVID-19 infection prevention and control requirements.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 3, 2020
Visit Reason
An offsite video surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
The facility was found to be in compliance with no deficiencies cited. Complaint NM# 44116 was unsubstantiated.
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 survey.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 11
Mar 5, 2020
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted to investigate substantiated complaints #NM41541, #NM42872, and #NM42334 regarding compliance with state regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including staff training, admission and discharge agreements, facility reports and records, incident reporting, medication management, housekeeping, resident room furnishings, and memory care unit requirements. Several repeat deficiencies were noted, and some deficiencies posed risks of harm or injury to residents.
Complaint Details
Complaint #NM41541, #NM42872, and #NM42334 were substantiated with deficiencies cited.
Deficiencies (11)
| Description |
|---|
| Failed to ensure Direct Care Staff received all required annual trainings including fire safety, first aid, safe food handling, infection control, resident rights, and medication assistance. |
| Admission/Discharge agreements for residents did not include a refund policy for death compliant with NMAC 7.8.2.20 and Senate Bill 0335-2013. |
| Failed to maintain written emergency evacuation plans for both facility-only and community-wide disasters. |
| Failed to report incidents and submit follow-up investigation reports to the licensing authority within required timeframes for residents #6 and #7. |
| Failed to protect resident rights by neglecting to notify legal representatives when resident #5 left the facility without medications and was in need of medical attention upon return. |
| Failed to maintain a current custodial drug permit and ensure proper medication procurement, labeling, storage, and destruction in compliance with state regulations. |
| Prescribed medications for residents #1 and #2 were not readily available, not labeled in compliance with state regulations, and discontinued medications were not properly removed. |
| Medication Administration Records (MARs) for residents #1 and #2 were incomplete and inaccurate, lacking required information such as prescription labels and physician orders. |
| Poisonous cleaning supplies were stored unsecured in a cabinet accessible to residents in the kitchen area. |
| Residents were required to provide all furniture for their rooms, contrary to regulations requiring the facility to provide minimum furnishings. |
| Direct Care Staff failed to receive the required twelve (12) hours of annual dementia/Alzheimer's training for memory care residents. |
Report Facts
Residents present: 32
Deficiency repeat count: 2
Missed medication doses: Multiple missed doses for residents #1 and #2 due to unavailable medications
Hours of dementia training completed: 0.25
Hours of dementia training completed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DCS #3 | Direct Care Staff | Named in staff training and dementia training deficiencies |
| DCS #4 | Direct Care Staff | Named in staff training and dementia training deficiencies |
| DCS #5 | Direct Care Staff | Named in staff training and dementia training deficiencies |
| Executive Director | Confirmed missing refund policy, incident reporting failures, and medication issues | |
| Business Office Manager | Confirmed missing dementia training for DCS #3-5 | |
| Maintenance Director | Confirmed lack of emergency evacuation plans and unsecured cleaning supplies | |
| Administrator | Confirmed medication issues for residents #1 and #2 |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 4, 2020
Visit Reason
The visit was a Revisit/Follow-up survey to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 03/04/2020.
Inspection Report
Follow-Up
Deficiencies: 1
Mar 4, 2020
Visit Reason
The visit was a Revisit/Follow-up survey completed on 03/04/2020 to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility failed to ensure that Direct Care Staff had the required six hours of palliative/hospice care training annually, including one hour specific to the resident's Individual Service Plan. This deficiency could place three residents receiving hospice services at risk of harm due to inadequate staff training.
Deficiencies (1)
| Description |
|---|
| Failed to ensure Direct Care Staff had the required six hours of palliative/hospice care training annually, including one hour specific to the resident's Individual Service Plan. |
Report Facts
Residents receiving hospice services: 3
Required palliative/hospice care training hours: 6
Actual training hours received by DCS #2: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed that Direct Care Staff #2 had not received the required 6 hours of palliative/hospice care training in the past year | |
| Direct Care Staff #2 | Employee file reviewed showing only 1 hour of palliative/hospice care training in the past year |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Oct 30, 2019
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted on 10/30/2019 to investigate substantiated complaints #NM 40068 and #NM 40499 regarding compliance with state regulations for assisted living.
Findings
The facility was found deficient in multiple areas including staff training, resident evaluations, medication administration, hospice care training, and dementia/Alzheimer's training. Deficiencies included lack of required staff training documentation, incomplete resident evaluations, missing physician orders for medications, inadequate medication labeling, and insufficient hospice and memory care training for direct care staff.
Complaint Details
Complaint #NM 40068 and Complaint #NM 40499 were substantiated with deficiencies cited.
Deficiencies (5)
| Description |
|---|
| Failed to ensure Direct Care Staff received required orientation and annual trainings including first aid, safe food handling, confidentiality, resident rights, smoking policy, quality care methods, emergency procedures, medication assistance, and implementation of resident ISPs. |
| Failed to complete and maintain resident evaluations including physical functioning, diagnoses, and health conditions for 4 residents reviewed. |
| Failed to ensure physician orders were documented for medications listed on Medication Administration Records for 4 residents; medications not labeled properly; medication administration errors documented inadequately. |
| Failed to provide Direct Care Staff with required six (6) hours of annual palliative/hospice care training including one hour specific to resident's Individual Service Plan. |
| Failed to provide Direct Care Staff with required twelve (12) hours of annual dementia/Alzheimer's training for residents diagnosed with dementia. |
Report Facts
Residents on census: 37
Residents reviewed for evaluation compliance: 4
Residents receiving hospice services: 4
Residents diagnosed with dementia: 7
Required staff training hours - palliative/hospice: 6
Required staff training hours - dementia/Alzheimer's: 12
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Oct 9, 2019
Visit Reason
The inspection was conducted as a complaint survey based on Complaint Intake NM#37578, which was substantiated with deficiencies cited related to staffing and medication administration at the assisted living facility.
Findings
The facility failed to maintain minimum staffing ratios during resident sleeping hours, lacked documentation of staff medication training, had incomplete medication administration records missing brand and generic names, and did not ensure adequate trained staff coverage in the Memory Care Unit, leaving residents at risk of harm.
Complaint Details
Complaint Intake NM#37578 was substantiated. The complaint alleged lack of staff presence in the Memory Care Unit for at least 20 minutes and staff meetings causing absence of staff during shift changes.
Deficiencies (4)
| Description |
|---|
| Failed to ensure minimum staffing of 2 Direct Care Staff on duty/awake and 1 additional staff immediately available during resident sleeping hours. |
| Direct Care Staff assisting with self-administration of medications had not completed a state approved training course and lacked certificates of completion. |
| Medication Administration Records (MAR) did not include both brand and generic names for multiple residents' medications. |
| Failed to have at least one trained Direct Care Staff on duty/awake in the Memory Care Unit at all times, resulting in periods when the unit was left unattended. |
Report Facts
Resident census: 36
Memory Care Residents: 7
Dates with insufficient staffing: 17
Medications missing brand/generic names: 13
Inspection Report
Follow-Up
Deficiencies: 0
Mar 27, 2019
Visit Reason
The visit was a Revisit/Follow-up survey to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 03/27/19.
Inspection Report
Follow-Up
Deficiencies: 2
Feb 25, 2019
Visit Reason
The visit was a Revisit/Follow-up survey completed on 02/25/19 to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility was found to have an uncorrected deficiency related to admission agreements and staff specialty training for residents receiving hospice services. Specifically, the facility failed to ensure that the admission agreement included evidence of staff specialty training and that team meetings were convened prior to admitting or retaining residents receiving hospice services.
Deficiencies (2)
| Description |
|---|
| Failure to ensure admission agreement included information and evidence of staff specialty training when providing specialized (memory care unit) services. |
| Failure to convene team meetings prior to admitting or retaining residents receiving hospice services from an outside agency. |
Report Facts
Deficiencies cited: 2
Days notice for termination: 15
Days notice for changes: 30
Hours of palliative/hospice care training: 6
Hours of specific hospice resident training: 1
Date of follow-up survey: Feb 25, 2019
Inspection Report
Complaint Investigation
Deficiencies: 8
Jun 20, 2018
Visit Reason
The inspection was a Full-Onsite/Complaint Survey conducted on 06/20/18 to assess compliance with state requirements for assisted living facilities, triggered by substantiated complaints #30541 and #30764.
Findings
The facility was found deficient in multiple areas including staff training, admission agreements, resident records, individual service plans, medication administration, incident reporting, and hospice care coordination. Several residents' records lacked required documentation and training for staff was incomplete, posing potential risks to residents.
Complaint Details
Complaint Intake #30541 and #30764 were substantiated with deficiencies cited. The complaint involved incidents of resident abuse, neglect, and failure to report incidents timely. Specific findings included unreported resident-to-resident abuse, unwitnessed falls, and inadequate staff response.
Deficiencies (8)
| Description |
|---|
| Failure to ensure staff received required 16 hours of supervised training prior to providing unsupervised care, including first aid, safe food handling, and methods to provide quality care. |
| Admission agreements for residents did not include staffing ratios or evidence of staff specialty training for memory care services. |
| Resident records were disorganized, inaccessible, and lacked required documentation such as admission agreements, evaluations, and medication administration records. |
| Individual Service Plans (ISPs) were not developed or updated timely, lacked crisis prevention/intervention plans, and did not coordinate care with hospice agencies. |
| Medication administration deficiencies including failure to administer ordered medications timely, lack of documentation, and inadequate staff assistance with self-administration. |
| Incident reporting failures including delayed or missing reports of resident abuse, falls, and injuries. |
| Failure to maintain building and grounds in good repair, including broken locks on memory care unit doors. |
| Hospice care deficiencies including failure to convene team meetings prior to admitting residents to hospice and lack of coordination with hospice agency. |
Report Facts
Hours of supervised training required: 16
Hours of annual training required: 12
Number of residents reviewed for admission agreements: 3
Number of residents reviewed for records: 41
Number of residents reviewed for ISPs: 41
Number of residents reviewed for medication administration: 6
Number of residents involved in abuse incidents: 4
Number of residents involved in incident reporting findings: 6
Number of residents in memory care unit: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alana Curlee | Surveyor | Named as surveyor responsible for the inspection report |
Inspection Report
Original Licensing
Census: 3
Deficiencies: 8
Jan 24, 2018
Visit Reason
Initial survey completed on 01/24/18 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The facility was found deficient in multiple areas including staff qualifications, staff training, admissions and discharge agreements, custodial drug permits, nutrition, water temperature, and fire drill documentation. Specific deficiencies included lack of required training and certifications for direct care staff, missing admission agreement information, unsecured medications, improper food temperature maintenance, hot water temperatures exceeding safe limits, incomplete fire drill records, and failure to submit required employee abuse registry and criminal caregiver history screenings for private caregivers.
Deficiencies (8)
| Description |
|---|
| Direct Care Staff who assist residents with self-administration of medications lacked state approved training and certification. |
| Direct Care Staff who transport residents lacked documentation of required transportation safety training and clean driving records. |
| Applications and clearances from Employee Abuse Registry and Criminal Caregiver History Screening were not submitted or received for private caregivers. |
| Admissions/Discharge Agreements for residents did not include required information regarding termination if an appropriate placement is found. |
| Medication refrigerator in Memory Care Unit lacked a lock; discontinued medications were not removed from medication cart; medications were unsecured in resident rooms. |
| Prepared foods transported to residents' rooms were not maintained at required hot temperatures of 140 degrees Fahrenheit. |
| Hot water temperatures in resident rooms exceeded the maximum safe temperature of 110 degrees Fahrenheit. |
| Fire drill records lacked documentation of problems noted during drills and evacuation times in total minutes. |
Report Facts
Residents at risk: 3
Fee amount: 74
Fee breakdown: 24
Fee breakdown: 7
Medication temperature: 128
Medication temperature: 119
Hot water temperature: 128
Hot water temperature: 122
Hot water temperature: 124
Inspection Report
Life Safety
Deficiencies: 10
Nov 14, 2017
Visit Reason
An initial Life Safety Code survey was conducted at the facility per the provider's request to assess compliance with the Life Safety Code portion of the New Mexico State Requirements for Assisted Living Facilities for Adults.
Findings
Multiple deficiencies were identified including tripping hazards from door stops, unsealed smoke barrier penetrations, gaps in smoke barrier doors, improperly oriented evacuation plans, painted-over UL labels on fire-rated doors, insufficient exit discharge lighting, unsecured elevator equipment room door, and missing signage on the kitchen range hood system. The facility was found in substantial compliance and temporary licensure was recommended.
Deficiencies (10)
| Description |
|---|
| Door stop installations at main entrance doors pose a tripping hazard. |
| Several smoke barrier penetrations identified that must be sealed with approved material. |
| A 4" diameter penetration between floors in janitor's closet must be sealed. |
| Additional access panels needed in corridors to access smoke barrier walls; penetrations must be sealed. |
| Smoke barrier doors have 1/8" - 1/4" gaps that do not resist passage of smoke. |
| Evacuation plan near main reception counter not properly oriented toward nearest emergency exit. |
| UL labels painted over on numerous fire-rated doors and frames serving stairwells; labels must be visible. |
| Additional exit discharge lighting required at east exit stairwell door. |
| Elevator equipment room door must latch and lock and have barrier to prevent falls into shaft. |
| Kitchen range hood system must have signage stating exhaust fan shall be turned on prior to cooking. |
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