Deficiency Records for Los Alamos Wellness and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Los Alamos Wellness and Rehabilitation. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-26 | 2023-12-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-26 | 2023-12-01 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-10-26 | 2023-12-01 | 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 | 2023-10-26 | 2023-12-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-26 | 2023-12-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-26 | 2023-12-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-26 | 2023-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-26 | 2023-12-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-26 | 2023-12-01 | 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 | 2023-10-26 | 2023-12-01 | 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 | 2023-10-26 | 2023-12-01 | 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 | 2023-10-26 | 2023-12-01 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-10-26 | 2023-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-12-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-26 | 2023-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-12-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-26 | 2023-12-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-24 | 2023-12-01 | 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 | 2023-10-24 | 2023-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-24 | 2023-12-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-26 | 2023-10-26 | 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 | 2022-08-11 | 2022-09-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-11 | 2022-09-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-11 | 2022-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-21 | 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 | 2022-08-11 | 2022-09-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-11 | 2022-09-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-11 | 2022-09-21 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-11 | 2022-09-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-21 | 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 | 2022-08-11 | 2022-09-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-11 | 2022-09-21 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-08-11 | 2022-09-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-08-11 | 2022-09-21 | 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 | 2022-08-11 | 2022-09-21 | 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 | 2022-08-11 | 2022-09-21 | 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 | 2022-08-11 | 2022-09-21 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-11 | 2022-09-21 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-08-11 | 2022-09-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-11 | 2022-09-21 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-08-11 | 2022-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-11 | 2022-09-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-11 | 2022-09-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-16 | 2022-09-09 | 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 | 2022-08-16 | 2022-09-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-16 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-16 | 2022-09-09 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-08-16 | 2022-09-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-06 | 2022-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-06 | 2022-06-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-06 | 2022-06-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-06 | 2022-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-08 | 2022-01-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-08 | 2022-01-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-08 | 2022-01-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-28 | 2021-11-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-09-28 | 2021-11-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-28 | 2021-11-01 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-09-28 | 2021-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-28 | 2021-11-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-28 | 2021-11-01 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-09-28 | 2021-11-01 | Y |
| 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 | 2021-09-28 | 2021-11-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-09-28 | 2021-11-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-06 | 2021-06-20 | 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 | 2021-05-06 | 2021-06-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-06 | 2021-06-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-06 | 2021-06-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-06 | 2021-06-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-06 | 2021-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-06 | 2021-06-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-06 | 2021-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-06 | 2021-06-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-06 | 2021-06-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-06 | 2021-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-06-20 | N |
| Keep all essential equipment working safely. | Health | 2021-05-06 | 2021-06-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-05-05 | 2021-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-05 | 2021-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-05 | 2021-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-05 | 2021-05-31 | N |
