Inspection Reports for Westwind House
6600 Los Volcanes Rd NW, Albuquerque, NM, 87121
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 24, 2024, cited deficiencies related to staff qualifications, incomplete individual service plans, resident rights protections, and unsafe storage of oxygen tanks and hazardous chemicals. Earlier inspections showed a pattern of similar issues, including unsecured hazardous materials, incomplete documentation, and safety concerns such as fire safety and medication management. Complaint investigations included a substantiated case involving missing resident funds and fraudulent use of a debit card, with law enforcement involvement; other complaints were mostly unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges in staff compliance, resident care documentation, and safety practices, with no clear improvement trend in recent years.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
43 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 9
Date: Oct 24, 2024
Visit Reason
The inspection was a complaint survey completed on 10/24/2024 to investigate two complaint intakes related to the facility's compliance with state regulations for assisted living facilities.
Complaint Details
Two complaint intakes were investigated, both resulting in cited deficiencies. One complaint involved missing money and fraudulent use of a resident's debit card, with law enforcement involvement and a police report filed. The direct care staff member implicated was no longer employed at the facility at the time of investigation.
Findings
Deficiencies were cited related to staff qualifications, failure to submit applications and fingerprints to the Caregivers Criminal History Screening Program, incomplete individual service plans, failure to protect residents' legal rights including financial safeguards, unsafe storage of oxygen tanks, and unsafe storage of cleaning supplies and hazardous chemicals.
Deficiencies (9)
Facility failed to submit application and fingerprints for direct care staff to the Caregivers Criminal History Screening Program within 20 days of hire.
Individual Service Plans (ISP) were incomplete or not properly documented for residents.
Resident rights were not fully protected, including failure to prevent financial abuse and failure to provide legal rights information.
Oxygen tanks were not secured properly in the resident dining room, posing a safety hazard.
Cleaning supplies and hazardous chemicals were not stored securely, accessible to residents.
Extension cords were used improperly for holiday displays and other purposes, violating fire safety requirements.
Windows had bowed screens that were damaged and not repaired or replaced.
Laundry detergent was unsecured and accessible to residents, posing a safety risk.
Facility failed to maintain electrical system labeling and safe use of electrical cords.
Report Facts
Resident census: 43
Charges of electronic transfer: 3
Oxygen tanks unsecured: 6
Laundry detergent volume: 1.32
Window screens bowed: 20
Financial reimbursement: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DCS #1 | Direct Care Staff | Named in complaint investigation for fraudulent use of resident's debit card and failure to submit application and fingerprints to screening program. |
| Executive Director | Confirmed failure to submit staff application and fingerprints, reviewed staff screening, and acknowledged findings related to complaint and deficiencies. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 6
Date: Jun 5, 2023
Visit Reason
The inspection was a Full-Onsite/Complaint survey completed on 06/05/2023 for state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities for Adults, including investigation of multiple complaint intakes.
Complaint Details
Complaint Intake NM46249, NM53779, NM60414, and NM64851 were investigated with no deficiencies cited. The inspection included complaint-related investigation as part of the Full-Onsite survey.
Findings
The facility was found deficient in several areas including failure to post snacks on the daily menu, unsecured storage of hazardous chemicals, hot water temperatures exceeding allowed maximums in resident restrooms, window coverings and screens in disrepair, and incomplete fire drill documentation regarding evacuation times.
Deficiencies (6)
Facility failed to ensure that snacks were posted on the daily menu.
Cleaning supplies and hazardous chemicals were stored in unsecured areas accessible to residents.
Hot water temperatures in resident restrooms exceeded the maximum allowed 110 degrees Fahrenheit.
Window coverings and blinds were not in good repair, including broken and bent blinds in resident rooms.
Operable windows lacked screens or had damaged screens, risking resident exposure to bugs and allergens.
Monthly fire drills did not include recorded evacuation times in total minutes.
Report Facts
Resident census: 41
Number of cleaning supplies observed unsecured: 14
Hot water temperature: 139
Hot water temperature: 125
Fire drills missing evacuation times: 2
Inspection Report
Routine
Deficiencies: 0
Date: Oct 21, 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: Oct 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 COVID-19 infection prevention and control survey.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 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
Date: Aug 25, 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 22, 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: 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 22, 2020
Visit Reason
An offsite surveillance survey was conducted on 04/22/20 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 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 survey.
Inspection Report
Routine
Deficiencies: 0
Date: 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 survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 10, 2019
Visit Reason
The visit was a Revisit/Follow-up survey completed to verify compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living.
Findings
No deficiencies were cited during the Revisit/Follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 19, 2019
Visit Reason
The inspection was conducted as a complaint survey related to Complaint #NM 35062 to assess compliance with state regulations for assisted living.
Complaint Details
Complaint #NM 35062 was unsubstantiated with no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey, and the complaint was found to be unsubstantiated with no deficiencies noted.
Inspection Report
Follow-Up
Census: 42
Deficiencies: 2
Date: Sep 18, 2019
Visit Reason
The inspection was a Revisit/Follow up survey completed on 09/18/2019 to assess compliance with state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities.
Findings
The facility was found deficient in ensuring accurate and complete Admission/Discharge Agreements for residents and in securing medications properly. These deficiencies were uncorrected from a prior survey dated 11/19/2018 and posed potential risk of harm to residents.
Deficiencies (2)
Failed to ensure Admission/Discharge Agreements were accurate and complete, including proper termination conditions.
Failed to ensure all medications, including non-prescription drugs, were stored in a locked compartment or locked room.
Report Facts
Residents identified on census: 42
Residents with Admission/Discharge Agreements reviewed: 2
Date of prior survey with uncorrected deficiencies: Nov 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa R. Demart | Administrator | Administrator interviewed on 09/17/19 confirming missing information from Admission/Discharge Agreements and medication storage issues. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 15
Date: Nov 19, 2018
Visit Reason
The inspection was a Full-Onsite/Complaint survey completed on 11/19/2018 for the state requirements of 7 NMAC 8.2, Regulations for Assisted Living Facilities. Complaint NM#33289 was substantiated with deficiencies cited.
Complaint Details
Complaint NM#33289 was substantiated with deficiencies cited including a Class A deficiency related to neglect in emergency medical response for resident #6.
Findings
Multiple deficiencies were cited including staff qualifications, staff training, admissions and discharge procedures, resident evaluations, individual service plans, resident rights, medication management, laundry services, electrical system safety, door safety, fire extinguisher maintenance, fire drills, staff and resident fire safety training, and hospice care coordination. A Class A deficiency was cited related to failure to provide timely emergency medical services and proper care for a resident who died after a life-threatening event.
Deficiencies (15)
Staff qualifications not met for Resident Care Coordinator and Direct Care Staff regarding Employee Abuse Registry clearance and Caregiver Criminal History Screening submission.
Staff training deficiencies including lack of required supervised training hours and fire safety/evacuation training for Resident Care Coordinator and Direct Care Staff.
Admission and discharge agreements were inaccurate or missing, and team meetings were not convened prior to admitting/retaining hospice residents.
Resident evaluations were not reviewed and updated at least every six months or with significant health changes.
Individual Service Plans (ISP) were not reviewed or updated at least every six months or with significant health changes and lacked coordination with hospice care.
Resident rights were not fully protected; a Class A deficiency was cited for failure to provide timely emergency medical services, failure to call 911 promptly, and failure to properly train staff on emergency procedures.
Medication carts were not locked when unattended and residents managing their own medications lacked physician orders authorizing this.
Unlicensed Direct Care Staff performed invasive procedures such as finger sticks for diabetic residents; medication orders were not properly transferred to Medication Administration Records.
Laundry room cleaning supplies were accessible to residents and clean laundry was stored in an area contaminated with dirty laundry and garbage.
Electrical outlets within three feet of water supply were not equipped with Ground Fault Circuit Interrupter (GFCI) protection.
Public restroom doors did not readily open from the inside, posing a risk during emergencies.
Fire extinguishers were not inspected monthly as required; inspection tags were blank for several months.
Fire drills were not conducted or documented correctly, including missing drills, missing evacuation times, and no drills during night shifts.
Staff and residents did not receive fire safety and evacuation training as required; residents did not receive orientation on fire safety upon admission.
Hospice care deficiencies included failure to convene team meetings prior to admitting/retaining hospice residents and failure to update Individual Service Plans to include hospice care coordination.
Report Facts
Residents on census: 44
Deficiency count: 15
Fine amount: 5000
Fingerprint submission timeframe: 20
Fire extinguisher inspection interval: 30
Fire drill frequency: 1
Fire drill shifts: 3
Fire drill missing months: 1
Fire drill missing evacuation times: 3
Fire drill missing night drills: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Named in findings related to Employee Abuse Registry clearance and Caregiver Criminal History Screening submission delays. | |
| Direct Care Staff #2 | Named in findings related to Employee Abuse Registry clearance and Caregiver Criminal History Screening submission delays. | |
| Direct Care Staff #3 | Named in findings related to Employee Abuse Registry clearance and Caregiver Criminal History Screening submission delays. | |
| Direct Care Staff #1 | Named in emergency medical neglect findings related to resident #6. | |
| Direct Care Staff #4 | Observed performing invasive procedures without nursing license. | |
| Administrator | Interviewed regarding multiple deficiencies including emergency response, fire drills, and staff training. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 2, 2011
Visit Reason
A complaint investigation was conducted for intake NM00027918 to determine compliance with regulations.
Complaint Details
Complaint intake NM00027918 was investigated and found unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 1, 2010
Visit Reason
The inspection was conducted as a complaint survey on 12/01/2010 for the requirements of NMAC 7.8.2, regulations governing New Mexico Assisted Living Facilities. Complaint #27364 was investigated and found to be substantiated.
Complaint Details
Complaint #27364 was investigated and found to be substantiated for NMAC 7.8.2.31 A.
Findings
The facility failed to notify the designated guardian for one resident requiring hospital transport in a timely manner, with notification delayed over 14 hours after the incident. The Care Coordinator acknowledged this failure and corrective actions were planned.
Deficiencies (1)
Facility failed to contact the designated guardian for one resident requiring hospital emergency transport in a timely manner.
Report Facts
Complaint number: 27364
Resident count related to deficiency: 1
Incident report dates: 2
Completion date: Feb 17, 2011
Inspection Report
Life Safety
Census: 37
Capacity: 48
Deficiencies: 6
Date: Sep 16, 2009
Visit Reason
A Life Safety Code survey was conducted on September 16, 2009, for New Mexico Requirements for Adult Residential Care Facilities 7.8.2 NMAC.
Findings
The facility failed to provide written policies and procedures for automatic sprinkler and fire alarm systems being out of service for more than 4 hours within a 24-hour period. Additionally, the facility failed to ensure the range hood system was inspected every six months, and oxygen storage did not comply with NFPA 99 standards. Several fire safety deficiencies were identified that could affect residents, staff, and occupants.
Deficiencies (6)
Failed to provide written policies and procedures for automatic sprinkler system being out of service for more than 4 hours within a 24-hour period.
Failed to provide written policies and procedures for fire alarm system being out of service for more than 4 hours within a 24-hour period.
Failed to ensure the range hood system was inspected by a professional company at least every six months as required by NFPA 96.
Oxygen cylinders were not stored in compliance with NFPA 99 standards, including improper ventilation, lack of signage, and improper fire-rated construction of storage rooms.
The number of oxygen cylinders was greatly reduced and weekly delivery arranged, but storage conditions still required correction.
Liquid oxygen containers were stored in resident rooms without proper approved storage and transfer rooms.
Report Facts
Licensed capacity: 48
Census: 37
Oxygen cylinders: 61
Oxygen cylinders: 9
Oxygen cylinders: 73
Fire rated door: 3
Inspection dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma R Duarte | Administrator | Named in relation to findings about lack of policies and procedures and interviews regarding sprinkler and fire alarm systems, range hood inspections, and oxygen storage. |
Inspection Report
Deficiencies: 4
Date: Sep 15, 2009
Visit Reason
The inspection was conducted to assess compliance with state regulations for adult residential care facilities, focusing on admissions criteria, medication management, and employee background screening.
Findings
The facility was found deficient in multiple areas including failure to develop and approve individual service plans for residents, improper medication labeling and storage, lack of documentation and follow-up on medication administration, and incomplete employee background screening records.
Deficiencies (4)
Failure to develop, coordinate and approve a current individual service plan that meets the specific individual health needs of a high acuity bedbound resident.
Failure to ensure medications were labeled and stored in compliance with state and federal laws for one resident dependent on insulin shots.
Failure to ensure proper medication administration documentation including missing entries and follow-up on physician orders for residents with diabetes.
Failure to maintain documentation that direct care staff had been cleared through the New Mexico Caregivers' Criminal History Screening Program for two employees.
Report Facts
Date survey completed: Sep 15, 2009
Date of completion for individual service plan correction: Oct 1, 2009
Date of completion for custodial drug permit correction: Oct 15, 2009
Date of completion for medication administration correction: Oct 15, 2009
Date of completion for employee screening correction: Oct 4, 2009
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2009
Visit Reason
The inspection was conducted as a complaint investigation for New Mexico Regulations Governing Adult Residential Care Facilities 7.8.2 NMAC, specifically investigating complaint NM #27089.
Complaint Details
Complaint NM #27089 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
No deficiencies were cited during the complaint investigation conducted on 5/21/09-5/22/09. The complaint was unsubstantiated with no deficiencies found.
Inspection Report
Life Safety
Census: 32
Capacity: 48
Deficiencies: 2
Date: Jul 26, 2007
Visit Reason
The inspection was conducted as an annual life safety code survey for New Mexico Regulations Governing Requirements for Adult Residential Care Facilities.
Findings
Deficiencies were cited related to fire extinguishers and fire fighting equipment, including the need to upgrade the kitchen range hood to meet UL-300 fire code standards. The facility failed to ensure proper inspection and maintenance of fire extinguishers and related equipment.
Deficiencies (2)
Failure to have fire extinguishers properly inspected, tagged, and maintained as required by state fire authorities.
Nozzles in duct and plenum of kitchen range hood need to be upgraded to meet UL-300 Fire Code.
Report Facts
Licensed capacity: 48
Census: 32
Inspection Report
Annual Inspection
Census: 2
Deficiencies: 5
Date: Jul 23, 2007
Visit Reason
The inspection was conducted as an annual survey of Westwind House Assisted Living to assess compliance with regulatory requirements, including admissions, facility reports, staff training, resident funds handling, and facility maintenance.
Findings
The facility failed to convene required team meetings for residents receiving hospice services, failed to maintain documentation of ongoing staff training in fire safety and first aid, failed to provide written authorization for handling resident personal funds, and failed to maintain documentation of annual inspection and maintenance of the gas heater and hot water temperatures within required ranges.
Deficiencies (5)
Failed to convene a team to determine whether residents receiving hospice services should be allowed to remain in the facility.
Failed to maintain documentation of ongoing staff training in fire safety and first aid for sampled staff.
Failed to have written authorization from residents or legal representatives to handle personal funds for all residents.
Failed to provide documentation that the fuel-fired gas heater had been inspected annually by qualified personnel.
Failed to maintain hot water temperatures within the required range of 95-110 degrees Fahrenheit.
Report Facts
Residents receiving hospice services: 2
Staff training compliance: 3
Residents without written authorization for personal funds: 7
Gas heater inspection completion date: Aug 8, 2007
Hot water temperature range: 95
Hot water temperature range: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding failure to convene team meetings and staff training documentation |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 19, 2005
Visit Reason
The inspection was a routine regulatory survey of Westwind House Assisted Living to assess compliance with resident records, facility reports, policies, procedures, resident rights, medication administration, and incident reporting requirements.
Findings
The facility was found deficient in maintaining written consent for medication assistance, failure to administer medications as ordered, failure to report incidents timely, neglect of resident care including failure to check on a resident who was found deceased, and failure to follow physician orders for vital sign monitoring. Staff training and corrective actions were planned and implemented.
Deficiencies (5)
Failed to maintain documentation of written consent for assisting with medications for 1 of 3 residents.
Failed to follow facility policies and procedures resulting in neglect of 1 of 3 residents.
Failed to report an incident of abuse, neglect, and missed medications for 1 of 3 residents to Licensing Authority and Adult Protective Services by the next business day.
Failed to protect resident rights and assure freedom from physical, emotional abuse, and gross neglect for 1 of 3 residents.
Failed to have documentation of written consent for medication assistance, failed to administer medications at prescribed times, and failed to follow physician's order for daily blood pressure checks for 1 of 3 residents.
Report Facts
Missed blood pressure checks: 21
Missed medication administrations: 11
Medications not administered: 5
Suspension days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Terminated for not following facility policies regarding resident care and supervision. | |
| E3 | Terminated for not following facility policies regarding resident care and supervision. | |
| E7 | Suspended for 5 days for not following up with resident when she did not appear for her medications. | |
| Administrator | Facility Administrator | Interviewed regarding deficiencies in medication consent, incident reporting, and resident neglect. |
| Resident Care Coordinator | Involved in reviewing policies, monitoring staff compliance, and corrective actions. |
Inspection Report
Routine
Deficiencies: 16
Date: Oct 27, 2004
Visit Reason
The inspection was a routine regulatory visit to assess compliance with housekeeping, maintenance, life safety, fire safety, and other facility regulations.
Findings
The facility was found to have multiple deficiencies including housekeeping issues, maintenance problems such as cracks and doors not sealing, sprinkler obstructions, missing escutcheon plates, blocked fire alarm pull stations, electrical clearance obstructions, improper oxygen storage, inadequate ventilation, lighting issues, unlabeled circuit breakers, corridor obstructions, missing smoke detectors in resident rooms, fire extinguishers not inspected monthly, incomplete fire drill documentation, and smoking area deficiencies.
Deficiencies (16)
Bathroom exhaust vent had a thick film of dust and lint.
Cracks in ceiling in corridors and doors that do not seal properly.
Penetrations in 1-hour rated walls not sealed to maintain smoke resistance.
Sprinkler spray pattern obstructed by stored items within 18 inches of sprinkler heads.
Escutcheon plates missing or improperly installed on sprinkler heads.
Manual fire alarm pull stations obstructed by furniture.
Electrical room clearance blocked by chair and dolly.
Oxygen cylinders improperly stored in resident rooms, oxygen room door does not close and latch.
Storage room for cleaning supplies lacked mechanical exhaust ventilation causing strong odors.
Burnt light bulb in entry living room and uncovered fluorescent light fixture in janitor's closet.
Electrical breakers marked as spares were switched on and not properly labeled.
Corridors obstructed by oxygen tank left unattended in corridor.
Smoke detector missing in resident room #30 with exposed wiring.
Fire extinguishers not inspected monthly; last inspection was annual in May 2004.
Fire drills not conducted monthly in April and August 2004; fire alarm system use not documented.
Designated smoking area lacked suitable metal containers with self-closing lids.
Report Facts
Deficiencies cited: 16
Inspection Report
Routine
Deficiencies: 4
Date: Oct 22, 2004
Visit Reason
The inspection was conducted as a routine regulatory survey of Westwind House Assisted Living to assess compliance with state regulations regarding resident records, medication management, nutrition, and food safety.
Findings
The facility was found deficient in maintaining complete resident records, specifically missing photographs for 2 of 36 residents. Medication storage and labeling were inadequate, including unlocked medication refrigerators and expired medications. The facility failed to post menu changes and lacked a thermometer in one freezer. Corrective actions were planned and implemented for all deficiencies.
Deficiencies (4)
Two of 36 residents did not have photographs taken as required in their records.
Medications were not properly stored and labeled; refrigerator containing medicines was not locked and medications for staff were stored improperly.
Facility failed to post changes in the dinner menu as served.
One of two freezers did not have a thermometer to monitor temperature.
Report Facts
Residents without photographs: 2
Residents total: 36
Inspection date: Oct 22, 2004
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