Deficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 35
Deficiencies: 1
Sep 23, 2023
Visit Reason
The inspection was an offsite Revisit/Follow-up survey to verify correction of previously cited deficiencies related to hospice care training requirements for Direct Care Staff at an assisted living facility.
Findings
The facility failed to ensure that Direct Care Staff completed the required minimum of six hours per year of palliative/hospice care training. Documentation was missing for multiple staff members, indicating ongoing noncompliance with training requirements.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure Direct Care Staff completed a minimum of six hours per year of palliative/hospice care training as required. |
Report Facts
Direct Care Staff missing training documentation: 3
Resident Census: 35
Training hours required: 6
Inspection Report
Routine
Deficiencies: 0
Aug 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 COVID-19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Jul 16, 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
Jun 22, 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
Routine
Deficiencies: 0
Apr 21, 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
Routine
Deficiencies: 0
Apr 3, 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; no specific deficiencies or findings are detailed in the report.
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
Follow-Up
Deficiencies: 0
Sep 27, 2019
Visit Reason
The visit was a Revisit/Follow-up survey to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
No deficiencies were cited as a result of the Revisit/Follow-up survey completed on 09/27/19.
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Aug 15, 2019
Visit Reason
The inspection was a Full-Onsite/Complaint survey triggered by Complaint Intake NM#37514, which was substantiated.
Findings
The facility was found deficient in multiple areas including incomplete Admission/Discharge Agreements missing required elements such as refund provisions, staffing ratios, and termination notices; failure to document medication errors and prescriber responses for residents; and failure to conduct monthly fire drills for each 8-hour shift per quarter.
Complaint Details
Complaint Intake NM#37514 was substantiated with deficiencies cited related to admission agreements, medication administration documentation, and fire drill compliance.
Deficiencies (3)
| Description |
|---|
| Admission/Discharge Agreements for 4 residents lacked required information including refund provisions in case of death, staffing ratios, incident reporting rights, and 15-day termination notice. |
| Failure to document medication errors and prescriber's response in resident files for 26 residents, including specific incidents involving residents #1 and #5. |
| Failure to conduct monthly fire drills for each 8-hour shift (day, evening, night) per quarter from 01/01/19 to 08/01/19. |
Report Facts
Residents reviewed for Admission/Discharge Agreement compliance: 4
Residents at risk due to medication documentation deficiencies: 26
Residents at risk due to fire drill deficiencies: 26
Date of inspection: Aug 15, 2019
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 12, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to complaint intake #37012 regarding alleged abuse and neglect at the facility.
Findings
The facility was found to have failed to report incidents of alleged abuse or neglect to the Licensing Authority within the required 24 hours or next business day. The investigation revealed that a Wellness Director/Nurse was verbally and physically abusive to a resident, and the facility delayed reporting the incident. The Administrator confirmed the delay in reporting and the facility took disciplinary actions including suspension and training for the involved staff.
Complaint Details
Complaint intake #37012 was substantiated with deficiencies cited. The complaint involved the Wellness Director/Nurse attempting to remove a resident by force and verbal/physical abuse. The facility delayed reporting the incident from 04/29/19 to 05/03/19. The Wellness Director/Nurse was reprimanded, suspended for 7 days without pay, required to take dementia training, and later resigned. Multiple staff interviews and video evidence supported the findings.
Deficiencies (2)
| Description |
|---|
| Failure to report incidents of alleged abuse or neglect to the Licensing Authority within 24 hours or next business day. |
| Wellness Director/Nurse verbally and physically abusive to resident. |
Report Facts
Complaint intake number: 37012
Suspension duration: 7
Incident date: Apr 29, 2019
Report delay days: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director/Nurse | Named as the staff member who was verbally and physically abusive to the resident and involved in the complaint | |
| Administrator | Confirmed the delay in reporting the incident and disciplinary actions taken | |
| Direct Care Staff #2 | Witnessed verbal abuse by Wellness Director/Nurse and provided interview statements | |
| DCS #1 | Interviewed and reported witnessing verbal abuse and physical abuse by Wellness Director/Nurse | |
| Marketing Director | Reported on Wellness Director/Nurse's inappropriate behavior towards residents with dementia | |
| Internal Operations/Human Resources Manager | Reported on complaints and disciplinary actions related to Wellness Director/Nurse |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 10, 2013
Visit Reason
A complaint survey was conducted on 10/10/13 for NM28932 with an unannounced visit to the facility. The complaint was Not Substantiated but a related deficiency was cited per Assisted Living State Regulations.
Findings
The facility failed to re-evaluate and update the Individualized Service Plan (ISP) for one resident, which had the potential to cause harm due to history of falls and injury risk. The resident had multiple un-witnessed falls and required increased assistance with transfers, but the ISP was not updated accordingly.
Complaint Details
The complaint was Not Substantiated but a related deficiency was cited per Assisted Living State Regulations.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement an Individual Service Plan (ISP) within required timeframes and update it to reflect resident needs, including assistance levels and fall prevention interventions. |
Report Facts
Un-witnessed falls: 6
Dates of falls: Falls occurred on 03/02/13, 03/10/13, 03/12/13, 03/14/13, 04/26/13, and 05/15/13.
Timeframe for ISP update: 10
Minimum ISP review interval: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Registered Nurse (RN) | Acknowledged last assessment done for resident and confirmed no updates since then. |
Inspection Report
Re-Inspection
Deficiencies: 5
Aug 3, 2010
Visit Reason
The inspection was conducted as a re-visit survey following previous deficiencies noted on 2010-05-03 and 2010-08-03, focusing on compliance with food management and sanitation regulations at the assisted living facility.
Findings
The facility was found to have repeat deficiencies related to food management and kitchen cleanliness, including failure to maintain cleaning schedules, inadequate staff training, and improper food storage and sanitation practices. The provider submitted a plan of correction addressing these issues with scheduled cleaning, staff training, and compliance with state regulations.
Deficiencies (5)
| Description |
|---|
| Failure to provide an acceptable plan of correction and repeat violations related to food management and sanitation. |
| Failure to ensure general visual cleanliness of the kitchen area, including encrusted buildup on equipment and lack of cleaning schedules. |
| Failure to follow the Plan of Correction regarding staff training on food service practices and documentation. |
| Failure to maintain proper refrigeration and freezer temperatures and proper food storage and labeling. |
| Failure to maintain cleaning schedules and proper sanitation of kitchen equipment and surfaces. |
Report Facts
Dates of prior surveys: Repeat deficiencies noted on 2010-05-03 and 2010-08-03
Date of cleaning schedule enforcement: Cleaning schedule established 2010-02-10 to be enforced by Executive Chef
Temperature requirements: 45
Temperature requirements: 35
Temperature requirements: 0
Supply requirements: 3
Supply requirements: 5
Inspection Report
Re-Inspection
Deficiencies: 3
May 3, 2010
Visit Reason
This is a re-visit survey conducted on 05/03/2010 to verify correction of previous deficiencies related to food management and sanitary conditions at Rainbowvision Santa Fe.
Findings
The facility failed to protect food in a clean and sanitary manner, with deficiencies including lack of hair restraints on kitchen staff, inadequate cleaning schedules, and poor cleanliness of kitchen equipment. The Administrator and Communications Director acknowledged these findings during the exit interview.
Deficiencies (3)
| Description |
|---|
| Failure to ensure kitchen staff wore effective hair restraints while preparing, cooking, and serving food. |
| Failure to maintain cleanliness and sanitary conditions in refrigerators, freezers, kitchen area, and food preparation areas. |
| Lack of a documented cleaning schedule and inadequate enforcement of kitchen sanitation policies. |
Report Facts
Date of original survey: May 3, 2010
Number of Life Safety Code surveyors: 2
Date of cleaning schedule establishment: Feb 10, 2010
Date of planned food prep training: Mar 15, 2010
Inspection Report
Life Safety
Census: 15
Capacity: 52
Deficiencies: 17
Jan 27, 2010
Visit Reason
An annual Life Safety Code survey was conducted on January 27, 2010, to assess compliance with New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in multiple areas including housekeeping/laundry services, building construction, maintenance of building and grounds, hazardous areas, heating, ventilation and air-conditioning, sewage and waste disposal, electrical system elements, fire clearance and inspections, and automatic fire protection sprinkler system. Several deficiencies were repeats from prior surveys and had the potential to affect all residents, staff, and visitors.
Deficiencies (17)
| Description |
|---|
| Facility failed to ensure food or dry goods were not exposed to soiled holding and housekeeping areas. |
| Entrance vestibule from service corridor to dry goods storage was used as janitors closet and soiled laundry storage without approval. |
| Facility failed to report new construction to Licensing Authority and failed to submit building and floor plans for review and approval. |
| Facility failed to maintain fire and smoke barrier doors and walls, including positive latching and no impediments to door closing. |
| Maintenance shop door was propped open preventing door self-closure as intended. |
| Doors to liquor storage closet were hollow core and not fire rated, impeding egress path. |
| Laundry room door was propped open preventing door self-closure. |
| Vertical shaft in laundry room service area had unfinished sheet rock and penetrations around ducting. |
| Door to laundry room service area with commercial gas dryers was missing the closing device. |
| Kitchen hood exhaust fan grills were covered in grease and baked on residue. |
| Exhaust fan failed to vent air in 2nd floor assisted living laundry room. |
| Trash disposal was not discarded in an environmentally safe and sound manner. |
| Electrical systems and components such as panels, conduit, junction boxes, disconnect switches, and wiring were not properly installed or maintained. |
| Run of 1/2-inch conduit in laundry room service area was not tied down or supported properly. |
| 22 wires of data/phone cable protruded from wall and were not properly secured. |
| Facility failed to ensure fire marshal inspections were conducted and documentation provided. |
| Sprinkler system was not properly maintained, inspected, or installed according to NFPA standards. |
Report Facts
Licensed capacity: 52
Census: 15
Survey date: Jan 27, 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged findings during the survey. | |
| Administrator | Interviewed and acknowledged findings during the survey. | |
| Assistant Head Cook | Interviewed regarding kitchen hood cleaning. |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 294
Deficiencies: 4
Jan 26, 2010
Visit Reason
Four complaint investigations were completed on 01/27/2010 for New Mexico Regulations Governing Adult Residential Care Facilities. The visit was to investigate these complaints and assess compliance with personnel and food management regulations.
Findings
The facility failed to ensure that one of two personnel transporting residents had a certificate of training on file, and kitchen staff failed to use proper hair restraints while preparing food. Additionally, the facility did not maintain documentation for criminal history screening for two employees and failed to post the Incident Management Information poster as required.
Complaint Details
Four complaint investigations were completed and all were unsubstantiated as noted in the opening remarks. However, deficiencies were found related to personnel training, food management, criminal history screening, and incident reporting.
Deficiencies (4)
| Description |
|---|
| One of two personnel transporting residents did not have a certificate of driver training on file. |
| Kitchen staff observed preparing and serving food without necessary hair restraints. |
| Facility failed to maintain documentation that direct care staff had been cleared through the New Mexico Caregivers' Criminal History Screening Program for two employees. |
| Facility failed to ensure that the Incident Management Information poster was posted as required. |
Report Facts
Complaint investigations: 4
Census: 15
Total licensed capacity: 294
Dates of complaint intakes: 4 complaint intake dates: 4/13/2009, 7/19/2009, 2/9/2009, 12/23/2009
Inspection Report
Follow-Up
Deficiencies: 4
May 14, 2008
Visit Reason
The inspection was conducted as a follow-up to verify correction of previous deficiencies related to emergency drainage of the assisted living spa tub, admission/discharge agreements, resident rights, and incident management.
Findings
The facility had ongoing issues with the emergency drainage system of the spa tub, admission/discharge agreements lacked specific and detailed information, resident rights protections were incomplete, and incident management documentation and notification processes were deficient. Corrective actions and plans were in place to address these issues.
Deficiencies (4)
| Description |
|---|
| The facility's only bath tub has a peculiar drainage method that caused water damage due to emergency button use and improper drainage. |
| The facility failed to provide an admission agreement with specific and detailed information about services, costs, and advance written notice of changes. |
| The facility failed to protect residents' rights by not furnishing residents with specific information about services, costs, and advance written notice of changes. |
| The facility failed to ensure that documentation of incident management notifications to family members and guardians was complete and accurate. |
Report Facts
Date of survey completion: May 12, 2008
Date of inspection visit: May 14, 2008
Recitation from prior survey: Mar 25, 2008
Number of times emergency button pressed: 4
Days for termination notice: 15
Number of resident rights items: 27
Date of signatures: Jul 9, 2008
Inspection Report
Annual Inspection
Census: 22
Capacity: 52
Deficiencies: 8
Mar 26, 2008
Visit Reason
The inspection was an annual life safety code survey conducted on 03/26/2008 for the Life Safety Code portion of the New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to maintain self-closing devices on doors to hazardous areas, failed to ensure annual fire inspections by local fire authorities, and failed to provide evidence of quarterly sprinkler system inspections and proper maintenance. Additional deficiencies included failure to ensure kitchen hood system cleaning and fire drills documentation. The Administrator and Environmental Services Director acknowledged these findings.
Deficiencies (8)
| Description |
|---|
| Facility failed to maintain a self-closing device for doors to hazardous areas, with door stops preventing proper closure. |
| Facility failed to ensure annual inspection by local fire prevention authority; no evidence of inspection was available. |
| Facility failed to provide evidence of quarterly sprinkler system inspections for the past 12 months. |
| Sprinkler head missing escutcheon cup and boxes stored too close to sprinkler deflectors. |
| Facility failed to ensure cooking facilities are inspected and cleaned according to NFPA 96 standards; range hood sprinklers covered with grease residue. |
| Facility failed to provide evidence that the kitchen hood system and its appurtenances were professionally cleaned at least every six months. |
| Facility failed to conduct at least one fire drill each month with proper documentation; fire drills were not consistently conducted or documented. |
| Facility failed to provide staff and resident fire and safety training as required. |
Report Facts
Licensed capacity: 52
Census: 22
Date of survey: Mar 26, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Acknowledged findings and responsible for ongoing compliance and scheduling inspections. | |
| Facility Manager | Participated in record reviews and acknowledged deficiencies related to fire drills and sprinkler inspections. | |
| Administrator | Acknowledged findings at exit conference and involved in corrective actions. | |
| Executive Chef | Responsible for ensuring range hood sprinklers are maintained and kept clean. |
Inspection Report
Annual Inspection
Deficiencies: 10
Mar 25, 2008
Visit Reason
The inspection was conducted as an annual survey to assess compliance with licensing regulations and facility standards.
Findings
The facility was found to have multiple deficiencies including failure to submit all employee background screening information, falsification of fire drill records, failure to provide proper admission agreements, inadequate staff training records, failure to protect resident rights, insufficient snack availability, and failure to maintain fire protection systems. Corrective actions were planned or underway for all deficiencies.
Deficiencies (10)
| Description |
|---|
| Facility failed to submit all employee names and background screening information to the Caregivers Criminal History Screening Program. |
| Facility failed to ensure records presented to licensing authority were not misrepresentations or falsifications, including falsified fire drill records. |
| Facility failed to provide an admission agreement with specific information about services, costs, and advance written notice of changes. |
| Facility failed to ensure staff training records were kept as required for safe food handling practices. |
| Facility failed to protect resident rights by furnishing residents with written descriptions of legal rights and services provided. |
| Facility failed to ensure snacks were available between meals and in the evening. |
| Facility failed to ensure a functional tub was available to allow for residents bathing preference. |
| Facility failed to ensure the sprinkler system was professionally maintained. |
| Facility failed to ensure at least one fire drill was conducted for the assisted living area each month. |
| Facility failed to ensure required documentation of training on Incident Management. |
Report Facts
Date survey completed: Mar 25, 2008
Completion Date for falsification corrective action: Apr 24, 2008
Completion Date for admission agreement corrective action: May 10, 2008
Completion Date for food handling training corrective action: Apr 24, 2008
Completion Date for snack availability corrective action: Apr 24, 2008
Completion Date for tub availability corrective action: May 1, 2008
Completion Date for sprinkler system corrective action: Apr 24, 2008
Completion Date for fire drill corrective action: Apr 24, 2008
Completion Date for incident management training corrective action: Apr 24, 2008
Completion Date for incident management training annual update: May 10, 2008
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 21, 2006
Visit Reason
This document is a statement of deficiencies and plan of correction for Rainbowvision Santa Fe, LLC, related to regulatory compliance with New Mexico Regulations Governing Adult Residential Care Facilities.
Findings
No deficiencies were cited; the facility is in compliance with all applicable regulations.
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