Deficiencies per Year
8
6
4
2
0
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 4
Nov 15, 2024
Visit Reason
The inspection was conducted as a complaint survey completed on 11/15/24 to investigate a complaint intake ID related to the Village at Northrise - Desert Willow II assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to maintain personnel records for direct care staff, lack of recreational and social activities for residents, incomplete medication administration records for several residents, and failure to ensure staff completed required dementia training. These deficiencies could likely result in harm to the 21 residents identified on the census.
Complaint Details
Complaint intake ID was investigated during the survey completed on 11/15/24. Deficiencies were cited related to personnel records, resident activities, medication administration, and staff dementia training.
Severity Breakdown
C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to maintain personnel records for 2 direct care staff members, risking harm to 21 residents. | — |
| Failure to provide recreational and social activities and post an activities calendar for residents. | — |
| Incomplete Medication Administration Records (MAR) for 6 residents, including missed documentation of medication doses and pain medication administration. | — |
| Failure to ensure staff completed 12 hours of annual dementia training as required for memory care unit staff. | C |
Report Facts
Residents identified on census: 21
Direct Care Staff (DCS) missing personnel records: 2
Residents with incomplete MARs: 6
Hours of dementia training required: 12
Staff missing dementia training: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Named in findings related to missing personnel records and dementia training | |
| License Practical Nurse (LPN) #1 | Interviewed regarding resident activities and medication administration | |
| Director of Health and Wellness | Responsible for monitoring corrective actions and medication audits |
Inspection Report
Routine
Deficiencies: 0
Aug 24, 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 24, 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 18, 2020
Visit Reason
An Offsite Surveillance survey was conducted related to COVID-19 infection prevention and control.
Findings
No deficiencies were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
May 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
Mar 16, 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
Mar 11, 2020
Visit Reason
Revisit/Follow-up survey conducted to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 03/11/2020.
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 3
Dec 5, 2019
Visit Reason
A full onsite annual survey was conducted to assess compliance with state regulations for assisted living facilities, including admission/discharge agreements, medication administration, and fire safety.
Findings
The facility was found deficient in ensuring admission/discharge agreements included required refund policies and termination clauses, documenting coordination of care on individual service plans, properly documenting PRN medication administration and results, and conducting fire drills using the fire alarm system.
Deficiencies (3)
| Description |
|---|
| Admission/Discharge agreements lacked required refund policy for death, termination clause, and evidence of coordination of care on individual service plans. |
| Medication Administration Records (MAR) failed to document date/time and results of PRN medications given. |
| Fire drills were conducted without utilizing the fire alarm system, risking alarm failure and inadequate staff/resident response. |
Report Facts
Residents at risk: 22
Fire drills without alarm use: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 8, 2010
Visit Reason
A complaint investigation was conducted for intake #27599.
Findings
The investigation concluded that the complaint was unsubstantiated.
Complaint Details
Complaint investigation was unsubstantiated.
Inspection Report
Life Safety
Deficiencies: 0
Dec 23, 2008
Visit Reason
An annual unannounced Life Safety Code survey was conducted to assess compliance with New Mexico State Regulations governing Adult Residential Care Facilities.
Findings
The facility was found to be in compliance with the Life Safety Code portion of New Mexico State Regulations, and no deficiencies were cited.
Inspection Report
Original Licensing
Deficiencies: 0
Dec 18, 2008
Visit Reason
This is the original licensing inspection for Village at Northrise - Desert Willow I facility in Las Cruces, 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
Complaint Investigation
Deficiencies: 0
Jun 10, 2008
Visit Reason
A complaint survey was initiated on 2008-06-02 and completed on 2008-06-10 to investigate compliance with Requirements for Adult Residential Care Facilities 7.8.2 NMAC.
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 identified.
Complaint Details
A complaint survey was initiated on 2008-06-02 and completed on 2008-06-10. The facility was found to be in compliance with the requirements.
Inspection Report
Life Safety
Deficiencies: 1
Dec 12, 2006
Visit Reason
An annual life safety code survey was conducted on 12/12/06 for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure circuit breakers located in electrical panels were identified in a manner that allows for quick identification of a particular circuit. Specifically, two circuit breaker panels in the laundry area had circuits not clearly identified to correspond to the panel listing.
Deficiencies (1)
| Description |
|---|
| Circuit breakers located in electrical panels were not identified in a manner that allows for quick identification of a particular circuit. |
Report Facts
Circuit breaker panels observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Participated in the tour of the facility and explained how circuits are identified on the panels. | |
| Administrator | Participated in the tour of the facility during the inspection. | |
| Surveyor 17700 | Surveyor | Conducted the inspection and cited the deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 6
Dec 12, 2006
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations for the Village at Northrise-Desert WI facility, including review of resident records, nutrition, building maintenance, and other regulatory requirements.
Findings
The facility was found deficient in several areas including incomplete staff signatures on medication administration records, missing admission agreements for some residents, lack of TB test results for some staff, failure to maintain proper freezer temperatures, and unsafe electrical conditions in the kitchen. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (6)
| Description |
|---|
| Staff entries on the medication administration record were not signed for 1 of 3 residents. |
| Facility failed to have admission agreements for 2 of 5 residents. |
| Facility failed to have TB test results on file for 2 of 3 staff members. |
| Facility failed to maintain freezer temperature at 0 degrees Fahrenheit or below; freezer was observed at +15 degrees Fahrenheit. |
| Circuit breaker box in the kitchen did not have the protective cover installed, exposing high voltage electrical connections. |
| Facility failed to post between meal snacks on the weekly menu. |
Report Facts
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Program Manager | Acknowledged lack of staff signatures on medication administration records and other deficiencies during interviews | |
| Business Office Manager | Acknowledged missing admission agreements during interview | |
| Staff Development Coordinator | Audited employee files for TB test results and confirmed missing documentation | |
| Maintenance Supervisor | Responsible for maintenance issues including cleaning freezer filters and addressing electrical safety concerns | |
| Admissions Director | Responsible for completing admission agreements as part of corrective action |
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