Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Mar 20, 2023
Visit Reason
The inspection was a Full-Onsite/Complaint Survey conducted on 03/20/2023 to investigate complaint intake #60717 with deficiencies cited, along with other complaint intakes that were investigated with no deficiencies.
Findings
The facility was found deficient in maintaining resident records, individual service plans, and reporting incidents timely. Specific failures included incomplete resident records, lack of documentation of state reportable incidents, failure to complete and update individual service plans timely, and failure to report incidents of possible abuse and injury to the Licensing Authority within required timeframes.
Complaint Details
Complaint intake #60717 was investigated with deficiencies cited. Other complaint intakes (#58968, #56338, #56359, #60630) were investigated with no deficiencies cited.
Deficiencies (3)
| Description |
|---|
| Resident records were not maintained onsite in an organized, accessible, and permanent manner; entries were not legible, dated, or authenticated; non-current records were not maintained for five years; resident evaluation forms and ISPs were not completed or updated timely. |
| Individual Service Plans (ISP) were not developed and implemented within ten calendar days of admission and not reviewed or updated as required. |
| Failure to report incidents of possible abuse, neglect, exploitation, or unusual occurrences to the Licensing Authority within 24 hours or the next business day and failure to submit investigation/follow-up reports within five business days. |
Report Facts
Census: 107
Complaint intake number: 60717
Complaint intake numbers: 4
Residents reviewed for ISP compliance: 3
Residents with incident reports reviewed: 9
Days for ISP completion: 10
Days for incident reporting: 5
Hours for incident reporting: 24
Inspection Report
Follow-Up
Census: 104
Deficiencies: 1
Nov 23, 2022
Visit Reason
The inspection was an offsite Revisit/Follow-up survey conducted to verify correction of previously cited deficiencies related to staff qualifications and employee abuse registry compliance.
Findings
The facility failed to ensure that Direct Care Staff received clearances from the Employee Abuse Registry prior to hire, with specific instances of delayed clearance noted. A plan of correction was submitted outlining audits and monitoring to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Direct Care Staff received Employee Abuse Registry (EAR) clearances prior to hire. |
Report Facts
Resident census: 104
Fine amount: 5000
Employee clearance delays: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed during interview that DCS #1 and #3 EAR clearances were not completed prior to hire. | |
| Executive Director | Executive Director | Provided census data and is referenced in audit and quality assurance processes. |
Inspection Report
Follow-Up
Census: 104
Deficiencies: 1
Aug 4, 2022
Visit Reason
This offsite Revisit/Follow-up survey was conducted to verify compliance with state requirements following previous deficiencies cited at The Woodmark at Uptown.
Findings
The facility was found to have an uncorrected deficiency related to staff qualifications, specifically the failure to ensure that Direct Care Staff received clearances from the Employee Abuse Registry prior to hire, potentially affecting resident safety and welfare.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that Direct Care Staff received clearances from the Employee Abuse Registry prior to hire. |
Report Facts
Resident census: 104
Deficiency dates: 2
Monetary penalty limit: 5000
Inspection Report
Follow-Up
Census: 104
Deficiencies: 1
Jun 23, 2022
Visit Reason
This onsite Revisit/Follow-up survey was conducted to verify compliance with the state requirements of 7 NMAC 8.2, Regulations for Assisted Living, following a prior survey dated 12/09/21.
Findings
The facility was found to have an uncorrected deficiency related to staff qualifications, specifically the failure to ensure that Direct Care Staff had submitted applications and fingerprints for the Caregivers Criminal History Screening Program within 20 days of hire. Documentation for one employee was missing.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Direct Care Staff had applications and fingerprints submitted for Caregivers Criminal History Screening Program within 20 days of hire. |
Report Facts
Residents identified: 104
Fee amount: 74
Fee amount: 24
Fee amount: 7
Days: 20
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 7
Dec 9, 2021
Visit Reason
The inspection was a complaint survey completed on 12/09/21, substantiated for Complaint NM#52579 and Complaint NM#48886 with deficiencies cited related to staff qualifications, staffing ratios, admissions and discharge, resident evaluation, reporting of incidents, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to ensure staff qualifications and clearances from the Employee Abuse Registry and Caregivers Criminal History Screening Program, inadequate staffing ratios, incomplete admission/discharge agreements, failure to update resident evaluations, incomplete employee records, failure to report incidents timely, and failure to protect resident rights and provide a safe and sanitary living environment.
Complaint Details
Complaint NM#52579 and Complaint NM#48886 were substantiated with deficiencies cited.
Deficiencies (7)
| Description |
|---|
| Failure to ensure Direct Care Staff received clearances from the Employee Abuse Registry (EAR) prior to hire and Caregivers Criminal History Screening Program (CCHSP) fingerprint clearance within 20 days of hire. |
| Failure to maintain sufficient staffing levels to provide basic care, resident assistance, and required supervision based on residents' needs. |
| Failure to complete admission agreements including refund policy upon death as required by Senate Bill 0335 (2013). |
| Failure to maintain and update resident evaluations and assessments as required, including failure to update evaluations for residents with significant changes in health status. |
| Failure to maintain complete employee records including documentation of disciplinary actions and personnel records for review by Licensing Authority. |
| Failure to report incidents of suspected abuse, neglect, or exploitation within 24 hours to the Licensing Authority and to conduct timely investigations. |
| Failure to protect resident rights including providing a safe and sanitary living environment; specifically, residents' electric razors were stored together in a dirty container. |
Report Facts
Resident census: 99
Staff clearance timeframe: 20
Staffing ratio: 15
Staffing ratio: 30
Staffing ratio: 60
Audit completion date: Feb 12, 2022
Audit completion date: Feb 12, 2022
Audit completion date: Jan 28, 2022
Resident count: 9
Resident count: 4
Resident count: 2
Inspection Report
Routine
Deficiencies: 0
Aug 31, 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 surveillance survey.
Inspection Report
Monitoring
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 survey. The complaint intake #46159 was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint Intake #46159 was unsubstantiated with no deficiencies cited.
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 25, 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 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 measures.
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
No deficiencies were cited during the offsite surveillance survey.
Inspection Report
Routine
Deficiencies: 0
Mar 24, 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
Deficiencies: 0
Oct 30, 2019
Visit Reason
A complaint survey was conducted for intake NM 00039086 on 10/30/19 for the state requirements of 7 NMAC 8.2 Regulations for Assisted Living.
Findings
The complaint # NM 00039086 was unsubstantiated with no deficits cited.
Complaint Details
Complaint # NM 00039086 was unsubstantiated with no deficits cited.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 19, 2019
Visit Reason
The visit was a Revisit/Follow-up survey to verify compliance with state requirements for Assisted Living Facilities under 7 NMAC 8.2.
Findings
No deficiencies were cited during the Revisit/Follow-up survey completed on 2019-06-19.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Feb 22, 2019
Visit Reason
The inspection was conducted as a complaint survey related to allegations of abuse, neglect, and exploitation at the assisted living facility, Woodmark at Uptown, to assess compliance with state regulations.
Findings
The facility failed to report incidents of suspected abuse, neglect, and exploitation to the Licensing Authority within 24 hours or the next business day, and failed to submit follow-up investigation reports within five business days. These deficiencies put all 84 residents at potential risk of harm due to lack of oversight.
Complaint Details
Complaint #31878 and #33882 were unsubstantiated with no deficits cited. Complaint #30414 was unsubstantiated with deficits cited related to failure to timely report and investigate incidents of suspected abuse.
Deficiencies (2)
| Description |
|---|
| Failure to report incidents of suspected abuse, neglect, and exploitation within twenty-four (24) hours or the next business day if a weekend or holiday. |
| Failure to submit follow-up investigation reports to the Licensing Authority within five (5) business days from the date the incident occurred. |
Report Facts
Residents on census: 84
Days late for follow-up report: 132
Inspection Report
Follow-Up
Deficiencies: 0
Nov 17, 2017
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.
Findings
No deficiencies were cited during the Revisit/Follow-up survey, and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 9
May 23, 2017
Visit Reason
The inspection was a Full-Onsite/Complaint survey conducted on 05/23/17 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities. The complaint intake NM#30222 was substantiated with deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to apply for an amended Assisted Living License within ten business days of changing administrators, incomplete staff training and orientation records, inadequate written personnel policies, incomplete facility reports and records, failure to update resident evaluations and assessments, medication administration errors, unsafe storage and handling of medications, fire safety deficiencies, and inadequate hospice and memory care services documentation and training.
Complaint Details
Complaint Intake NM#30222 was substantiated with deficiencies cited related to licensing, staff training, resident care, medication administration, fire safety, and hospice/memory care services.
Deficiencies (9)
| Description |
|---|
| Facility failed to apply for an amended Assisted Living License within ten business days of changing Administrators. |
| Facility failed to ensure staff files had completed required orientation and annual training hours. |
| Facility failed to have adequate written personnel policies describing qualifications, conduct, training, and criminal history screening. |
| Facility failed to maintain required facility reports, records, policies, and procedures for review. |
| Facility failed to complete resident evaluations and assessments timely and accurately reflecting changes in condition. |
| Facility failed to ensure medication administration was properly documented and errors reported. |
| Facility failed to ensure medication refrigerator was locked and maintained proper temperature. |
| Facility failed to ensure fire alarm system and fire drills were conducted and documented timely. |
| Facility failed to provide required hospice and memory care training and documentation. |
Report Facts
Resident census: 124
Staff files reviewed: 9
Resident evaluations reviewed: 7
Medication Administration Records reviewed: 15
Fire drills documented: 1
Hours of hospice training: 6
Hours of Alzheimer's & Dementia training: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Mentioned in findings related to medication administration errors and incident reporting. | |
| Medication Aide (MA) #1 | Mentioned in findings related to unreported resident falls and medication administration. | |
| Director of Memory Care | Interviewed regarding resident assessments and hospice services. | |
| Business Office Manager | Provided resident census list and involved in policy and training audits. | |
| Administrator | Interviewed regarding licensing and incident reporting. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 3, 2013
Visit Reason
A complaint investigation was conducted for intake NM 00028933 on 10/03/13 for the state requirements of 7 NMAC 8.2 Regulations for Assisted Living.
Findings
The facility failed to ensure that medications were administered as ordered by the physician for one resident (R #1), resulting in missed doses and lack of documentation. Staff improperly administered medications instead of assisting residents as trained, and medications removed from blister packs were not given immediately, violating facility policies and training guidelines.
Complaint Details
The complaint was substantiated. Intake NM 00028933 indicated that resident #1 did not receive medications as ordered. Interviews and record reviews confirmed missed medication doses and improper medication administration practices.
Deficiencies (4)
| Description |
|---|
| Failed to ensure that medications were administered as ordered, causing one resident to miss medications. |
| Failed to document missed doses of medication on the Medication Assistance Record (MAR). |
| Staff trained to assist with medications were administering medications instead of assisting, potentially causing medication errors. |
| Medications removed from blister packs were not given immediately and were handled improperly (e.g., half a pill placed back in blister pack without gloves). |
Report Facts
Missed medication opportunities: 14
Number of residents sampled: 4
Number of staff assisting with medications: 15
Number of residents potentially affected: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | Interviewed regarding medication administration and documentation. | |
| Executive Director | Interviewed about staff assisting residents with medications. | |
| Clinical Director (RN) | Interviewed about medication administration and staff training. | |
| Med Tech #1 | Observed administering medications instead of assisting. | |
| Med Tech #2 | Observed administering medications and improper handling of blister pack medications. | |
| Resident's Case Manager (Complainant) | Reported that medications were not given to resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 2, 2012
Visit Reason
Complaint investigations were conducted for intake NM00028282 and intake NM00028476 on 08/02/12 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
The two complaints were unsubstantiated with no deficiencies cited.
Complaint Details
Two complaints investigated under intake NM00028282 and NM00028476 were found unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 1, 2009
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #NM00027191.
Findings
The facility was found to be in compliance with all New Mexico Regulations Governing Adult Residential Care Facilities 7 NMAC 8.2, and the complaint was unsubstantiated.
Complaint Details
Complaint #NM00027191 was investigated and found to be unsubstantiated.
Inspection Report
Life Safety
Census: 134
Capacity: 144
Deficiencies: 4
Sep 30, 2009
Visit Reason
The inspection was conducted as an annual survey for the Life Safety Code portion of the New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility was found deficient in several life safety code areas including exits not terminating directly to a public way, lack of approved smoke detectors in assembly areas, failure to conduct fire drills quarterly on every shift, and improper smoking area ashtray provisions.
Deficiencies (4)
| Description |
|---|
| Facility failed to assure one of two required exits terminate directly at a public way; exit discharge path was gravel and not usable in all weather conditions. |
| Facility failed to ensure approved smoke detectors were installed in areas of assembly such as the tea room. |
| Facility failed to conduct fire drills at least quarterly on every shift to assure preparedness for emergency response. |
| Facility failed to ensure self-closing metal containers were provided for disposal of cigarette butts in the designated smoking area. |
Report Facts
Licensed capacity: 144
Census: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Acknowledged concerns and findings during the inspection | |
| Administrator | Acknowledged findings at the exit conference on 09/30/09 | |
| Maintenance Director | Responsible for maintaining smoke detectors and fire drills | |
| Executive Director | Responsible for ensuring staff follows smoking policy |
Inspection Report
Life Safety
Census: 130
Capacity: 144
Deficiencies: 6
Jan 11, 2008
Visit Reason
The inspection was an annual Life Safety Code survey conducted on January 11, 2008, for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
The facility failed to ensure all fire protection systems, including smoke barriers and doors in smoke barriers, were self-closing or automatic closing and maintained in safe and functioning condition. Additional deficiencies included maintenance issues with corridor doors, electrical systems, hazardous areas, and automatic fire protection sprinkler systems.
Deficiencies (6)
| Description |
|---|
| Smoke barrier doors were not self-closing or automatic closing and did not latch properly, creating fire safety hazards. |
| Corridor doors were held open with devices such as chairs, kick stops, rubber wedges, and wooden sticks, preventing proper self-closing and latching. |
| Electrical outlets near water sources were not protected by Ground Fault Interrupters (GFI). |
| Hazardous areas were not properly enclosed or protected according to NFPA standards, including improper storage and signage. |
| Oxygen storage room had flooring and ventilation issues not compliant with regulations. |
| Automatic fire protection sprinkler system had obstructions and improper storage near sprinkler deflectors. |
Report Facts
Licensed capacity: 144
Census: 130
Inspection date: Jan 11, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to findings and corrective actions throughout the report | |
| Maintenance Director | Named in relation to findings and responsible for monitoring compliance and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 7, 2008
Visit Reason
The inspection was conducted to assess compliance with New Mexico Regulations Governing Adult Residential Care Facilities.
Findings
The facility was found to be in compliance with all applicable New Mexico regulations, with no deficiencies cited during the inspection.
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