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Deficiency Records for Santa Fe Post-Acute
A list of the most recent deficiencies for Santa Fe Post-Acute. 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 Post-Acute. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-31 | 2024-07-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-21 | 2023-11-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-21 | 2023-11-06 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-09-21 | 2023-11-06 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-09-21 | 2023-11-06 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-02 | 2023-09-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-09-08 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-07-14 | 2023-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-27 | 2023-08-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-07 | 2023-07-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-17 | 2023-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-13 | 2023-03-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-24 | 2022-11-16 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-20 | 2022-10-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-10-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-14 | 2022-08-12 | 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 | 2022-07-14 | 2022-08-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-07-14 | 2022-08-12 | 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 | 2022-07-14 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-14 | 2022-08-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-07-14 | 2022-08-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-14 | 2022-08-12 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-07-14 | 2022-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-15 | 2022-08-08 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-18 | 2022-08-08 | 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 | 2022-07-18 | 2022-08-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-18 | 2022-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-18 | 2022-08-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-18 | 2022-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-18 | 2022-08-08 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-03-08 | 2022-04-01 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-03-08 | 2022-04-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-25 | 2022-02-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Develop a communication plan. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-22 | 2019-04-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-07 | 2019-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-07 | 2019-04-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-04-04 | 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 | 2019-02-07 | 2019-04-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-07 | 2019-04-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-07 | 2019-04-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-02-07 | 2019-04-04 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-02-07 | 2019-04-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-02-07 | 2019-04-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-02-07 | 2019-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-02-07 | N |
| Keep all essential equipment working safely. | Health | 2019-02-07 | 2019-02-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-21 | 2018-02-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2017-12-21 | 2018-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-21 | 2018-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-21 | 2018-02-27 | 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 | 2017-12-21 | 2018-02-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2017-12-21 | 2018-02-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-12-21 | 2018-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-21 | 2018-02-27 | 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 | 2017-12-21 | 2018-02-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-12-21 | 2018-02-27 | 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 | 2017-12-21 | 2018-02-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2017-12-21 | 2018-02-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2017-12-21 | 2018-02-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2017-12-21 | 2018-02-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2017-12-21 | 2018-02-27 | 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 | 2017-12-21 | 2018-02-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-21 | 2018-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-21 | 2018-02-27 | N |
| Keep all essential equipment working safely. | Health | 2017-12-21 | 2018-02-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Develop a communication plan. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-01-10 | 2018-02-01 | N |
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