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Deficiency Records for Santa Fe Lodge
A list of the most recent deficiencies for Santa Fe Lodge. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Santa Fe Lodge. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-09-11 | 2024-09-27 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-03-07 | 2024-04-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-07 | 2024-04-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-07 | 2024-04-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-07 | 2024-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-07 | 2024-04-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-07 | 2024-04-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-07 | 2024-04-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-07 | 2024-04-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-07 | 2024-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-04-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-03-07 | 2024-04-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-07 | 2024-04-11 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-03-07 | 2024-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-04-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-07 | 2024-04-11 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-03-07 | 2024-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-04-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-03-07 | 2024-04-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-07 | 2024-04-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-13 | 2024-03-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-13 | 2024-03-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-03-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-13 | 2024-03-29 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-01-19 | 2024-02-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-02-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-02 | 2023-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-05-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-02 | 2023-05-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-10 | 2023-04-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-10 | 2023-04-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-10 | 2023-04-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-03-10 | 2023-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-10 | 2023-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-04-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-10 | 2023-04-11 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-03-10 | 2023-04-11 | N |
| Post nurse staffing information every day. | Health | 2023-03-10 | 2023-04-11 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-10 | 2023-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-04-11 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-03-10 | 2023-04-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-10 | 2023-04-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-10 | 2023-04-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-03-10 | 2023-04-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-13 | 2023-03-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-13 | 2023-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-13 | 2023-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-09 | 2022-08-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-28 | 2020-03-23 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2020-02-28 | 2020-03-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-21 | 2020-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-21 | 2020-03-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-21 | 2020-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-21 | 2020-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-21 | 2020-03-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-21 | 2020-03-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-02-21 | 2020-03-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-02-21 | 2020-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-21 | 2020-03-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-21 | 2020-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-21 | 2020-03-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-21 | 2020-03-19 | N |
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