Inspection Reports for Wellesley Care Home
3209 Wellesley Ct NE., Albuquerque, NM 87107, NM, 87107
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 18, 2020, found no deficiencies related to COVID-19 infection prevention and control. Earlier inspections from 2008 through 2020 were also generally free of deficiencies, except for a substantiated complaint investigation in April 2017 that identified multiple deficiencies across staff qualifications, training, medication management, safety, and housekeeping. This 2017 report included a finding of financial exploitation of a resident by staff and failure to submit a timely incident investigation report, but no fines or enforcement actions were listed in the available reports. Most complaints investigated were unsubstantiated, and no immediate jeopardy findings or license actions appeared. The facility’s inspection history shows improvement with no deficiencies noted in recent years following the 2017 issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 0
Date: Aug 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 COVID-19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 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.
Inspection Report
Routine
Deficiencies: 0
Date: 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
Routine
Deficiencies: 0
Date: Apr 23, 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
Date: Apr 2, 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
Date: Mar 18, 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
Date: Oct 18, 2017
Visit Reason
The visit was a Revisit/Follow-up survey conducted 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. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 28
Date: Apr 28, 2017
Visit Reason
Complaint intake NM#30134 was substantiated with deficiencies cited during a Full-Onsite survey for state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Complaint Details
Complaint intake NM#30134 was substantiated with deficiencies cited including financial exploitation of a resident by Direct Care Staff and failure to submit timely incident investigation report to Licensing Authority.
Findings
The facility was found deficient in multiple areas including staff qualifications, training, policies, admission agreements, resident evaluations, medication handling, nutrition, housekeeping, maintenance, fire safety, and complaint investigations. Specific issues included failure to obtain timely criminal background clearances, incomplete staff training, lack of emergency procedures, unsecured oxygen tanks, medication errors, financial exploitation of a resident by staff, and failure to submit timely incident investigation reports.
Deficiencies (28)
Failed to ensure Employee Abuse Registry (EAR) clearances were received prior to hire for 4 Direct Care Staff.
Failed to ensure Caregivers Criminal History Screening Program (CCHSP) applications and fingerprints were submitted within 20 days of hire for 4 Direct Care Staff.
Failed to ensure documentation/proof of applications, fingerprints, and clearances were maintained and available for review for 4 Direct Care Staff.
Failed to ensure 3 of 4 Direct Care Staff received required orientation and annual training in First Aid, Fire Safety and Evacuation, Smoking Policy, and Emergency Procedures.
Failed to have and implement a policy including emergency procedures for when the Fire Sprinkler System is out for 4 or more hours.
Admission agreements for 7 residents did not include the statement that the agreement may be terminated if an appropriate placement is found for the resident.
Failed to ensure resident evaluations were reviewed and updated at least every 6 months for 1 of 7 residents.
Failed to ensure Individual Service Plans (ISPs) were reviewed every 6 months for 1 of 7 residents.
Failed to obtain written consent to handle resident funds and maintain accurate accounting of resident funds for 1 resident.
Failed to submit documentation of internal investigation within 5 business days after incident of exploitation of a resident by Direct Care Staff.
Failed to ensure staff training files included Abuse/Neglect/Exploitation training for Direct Care Staff involved in exploitation incident.
Resident was financially exploited by Direct Care Staff who used resident's credit card for unauthorized purchases totaling approximately $1,000.
Failed to ensure staff wore hair nets or caps when handling food.
Failed to post weekly menu where residents and families could view it.
Failed to label and date food stored in refrigerator.
Oxygen cylinder tanks were unsecured and stored with combustibles in resident closets and storage shed was unventilated and contained combustibles.
Medication refrigerator was unlocked and several medications were not labeled with resident name or physician orders.
Failed to ensure physician orders for crushed medications and accurate Medication Administration Records (MAR) for 7 residents.
Medication MARs missing initials and signatures of medication technicians and resident's physicians not listed.
Medication MAR contained discontinued medications without physician orders and medications not on cart.
Facility failed to maintain clean, sanitary, odor free environment; multiple resident rooms and bathrooms had dirt, dust, urine odors, broken tiles, drywall penetrations, and dirty vents and sprinkler heads.
Facility failed to maintain safe storage areas; cleaning supplies stored in bathtub accessible to residents; linen closet unventilated and mixed with cleaning supplies; storage closet combustible, unventilated, disorganized, and unsecured.
Hot water heater pipe corroded and closet door broken; hot water temperature in resident bathrooms exceeded safe range (118°F).
Emergency light fixtures not all working and some missing covers; emergency lighting system not tested annually for 90 minutes; fire alarm circuit breaker not mechanically protected.
Electrical cords not U/L approved; multi-plug adapters used instead of direct wall plugs; GFCI outlets by sinks not functioning; washer and dryer not plugged into GFCI outlets.
Exit doors locked with deadbolts or button locks that cannot be opened with one motion; bathroom door handle loose and lock not operable with one motion; hot water heater closet door broken and difficult to open.
Facility failed to ensure resident bathrooms were clean, sanitary, free of bugs, spider webs, dirt, and mold; shower/bathtub used for mop storage; missing tiles and drywall penetrations in bathroom walls.
Direct Care Staff assisting memory care residents failed to receive required 12 hours of dementia/Alzheimer's training per year.
Report Facts
Residents: 16
Unauthorized credit card transactions: 43
Unauthorized credit card amount: 1149.92
Staff training hours: 12
Hot water temperature: 118
Emergency lighting test duration: 90
Medication Administration Records (MAR) review period: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DCS #1 | Direct Care Staff | Named in findings related to late criminal background clearances, incomplete training, medication administration, and memory care training |
| DCS #2 | Direct Care Staff | Named in findings related to late criminal background clearances, financial exploitation of resident, and abuse/neglect/exploitation training |
| DCS #3 | Direct Care Staff | Named in findings related to late criminal background clearances |
| DCS #4 | Direct Care Staff | Named in findings related to late criminal background clearances and exploitation incident |
| Administrator | Named in multiple interviews confirming deficiencies and incidents |
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 25, 2008
Visit Reason
The inspection was conducted to assess compliance with New Mexico Regulations Governing Adult Residential Care Facilities and the Life Safety Code portion of New Mexico State Regulations for Adult Residential Care Facilities.
Findings
No deficiencies were cited during the inspection. The facility was found to be in compliance with all applicable regulations and the Life Safety Code requirements.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 23, 2008
Visit Reason
The inspection was conducted as the 1st original licensing survey for Wellesley Care Home, LLC to determine 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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