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? |
|---|---|---|---|---|
| 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 |
| 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 | 2019-02-15 | 2019-03-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-15 | 2019-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-15 | 2019-03-18 | 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 | 2019-02-15 | 2019-03-18 | 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 | 2019-02-15 | 2019-03-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-02-15 | 2019-03-18 | 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 | 2019-02-15 | 2019-03-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-02-15 | 2019-03-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-15 | 2019-03-18 | N |
| Keep all essential equipment working safely. | Health | 2019-02-15 | 2019-03-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-02-15 | 2019-03-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-15 | 2019-03-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-15 | 2019-03-14 | 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 | 2019-02-15 | 2019-03-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-15 | 2019-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-15 | 2019-03-14 | N |
