Deficiencies per Year
4
3
2
1
0
Unclassified
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Mar 10, 2025
Visit Reason
The inspection was conducted as a complaint-only survey to investigate multiple complaint intakes regarding staffing and resident care at The Watermark at Cherry Hills.
Findings
The facility was found to be understaffed during the morning shift, failing to provide sufficient direct care staff to meet resident needs, particularly for residents requiring two-person assistance with transfers and activities of daily living. Some complaints were substantiated with evidence of delayed assistance and inadequate staffing ratios.
Complaint Details
Multiple complaint intakes were investigated; some complaints were not cited, while others were substantiated. The substantiated complaints included understaffing and delayed assistance for residents requiring two-person transfers, with one caller reporting a 2-hour wait for assistance after using the call bell.
Deficiencies (1)
| Description |
|---|
| Failure to ensure sufficient direct care staff on duty to provide basic care assistance and required supervision based on resident needs during the morning shift. |
Report Facts
Census: 101
Date of survey completion: Mar 10, 2025
Date of plan of correction completion: Mar 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Martinez | Executive Director | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 2, 2021
Visit Reason
The inspection was conducted as an Initial/Complaint survey triggered by substantiated complaint #NM44961 and unsubstantiated complaint #NM50325, to assess compliance with state regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including failure to complete individual service plans within 10 days of admission, failure to ensure resident rights, neglect resulting in a resident's death due to lack of oxygen administration and emergency care, and medication administration records lacking both brand and generic medication names for several residents.
Complaint Details
Complaint #NM44961 was substantiated with deficiencies cited. Complaint #NM50325 was unsubstantiated with no deficiencies cited.
Deficiencies (3)
| Description |
|---|
| Failure to complete individual service plans (ISP) within 10 days after admission for 1 of 4 residents reviewed. |
| Failure to ensure resident rights including safety and welfare, resulting in neglect and death of a resident who did not receive oxygen as ordered and emergency care was delayed. |
| Medication Administration Records (MARs) for 3 residents did not include both brand and generic names of medications. |
Report Facts
Residents with ISP deficiency: 1
Residents with MAR deficiency: 3
Oxygen order: 4
Oxygen saturation levels: 72
Time of incident: 3
Inspection Report
Routine
Deficiencies: 0
Oct 26, 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
Oct 23, 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
Aug 19, 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 survey.
Inspection Report
Routine
Deficiencies: 0
Jun 24, 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 23, 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 10, 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 survey.
Inspection Report
Routine
Deficiencies: 0
Mar 30, 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
Mar 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 survey.
Inspection Report
Routine
Deficiencies: 0
Mar 11, 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
Original Licensing
Deficiencies: 0
Jan 14, 2020
Visit Reason
An initial life safety code survey was conducted at the facility as per the provider's request.
Findings
The facility was found to be in substantial compliance with the New Mexico State Regulations for Assisted Living Facilities for Adults NMAC 7.8.2. Temporary licensure was recommended.
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