Deficiency Records for Santa Fe Heights Healthcare Center, LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Santa Fe Heights Healthcare Center, LLC. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-23 | 2024-03-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-23 | 2024-03-15 | N |
| 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 | 2024-02-23 | 2024-03-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-02-23 | 2024-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-23 | 2024-03-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-23 | 2024-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-23 | 2024-03-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-23 | 2024-03-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-23 | 2024-03-15 | 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 | 2024-02-23 | 2024-03-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-02-23 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-23 | 2024-03-15 | N |
| Dispose of garbage and refuse properly. | Health | 2024-02-23 | 2024-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-23 | 2024-03-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-02-23 | 2024-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-23 | 2024-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-22 | 2023-12-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-30 | 2023-11-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-28 | 2023-11-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-12 | 2023-10-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-10-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-06 | 2023-09-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-06 | 2023-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-06 | 2023-09-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-06 | 2023-09-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-17 | 2023-08-31 | 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 | 2023-07-17 | 2023-08-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-17 | 2023-08-31 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-17 | 2023-08-31 | 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 | 2023-08-15 | 2023-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-15 | 2023-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-27 | 2023-08-26 | Y |
| 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 | 2023-06-28 | 2023-07-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-28 | 2023-07-23 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-06-28 | 2023-07-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-05-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-26 | 2023-05-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-05-08 | 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 | 2023-04-07 | 2023-04-30 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-07 | 2023-04-30 | Y |
| 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 | 2023-03-20 | 2023-03-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-24 | 2023-03-06 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-02-10 | 2023-02-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-24 | 2022-10-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-24 | 2022-10-21 | Y |
| Provide appropriate foot care. | Health | 2022-09-24 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-17 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-05-10 | 2022-07-20 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-05 | 2022-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2021-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-10-08 | Y |
| 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 | 2021-08-02 | 2021-09-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-02 | 2021-09-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-02 | 2021-09-14 | 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 | 2021-08-02 | 2021-09-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-02 | 2021-09-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-02 | 2021-09-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-02 | 2021-09-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-02 | 2021-09-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-02 | 2021-09-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-02 | 2021-09-14 | 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 | 2021-08-02 | 2021-09-14 | N |
| Provide or obtain dental services for each resident. | Health | 2021-08-02 | 2021-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-02 | 2021-09-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-02 | 2021-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-02 | 2021-09-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-08-02 | 2021-09-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-02 | 2021-09-14 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-30 | 2021-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-30 | 2021-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-20 | 2021-08-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-20 | 2021-08-03 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-20 | 2021-08-03 | Y |
| 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 | 2021-07-20 | 2021-08-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-20 | 2021-08-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-21 | 2021-05-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-16 | 2021-05-03 | Y |
| 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 | 2021-04-16 | 2021-05-03 | Y |
| 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 | 2019-03-22 | 2019-05-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-22 | 2019-05-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-22 | 2019-05-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-22 | 2019-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-22 | 2019-05-30 | 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 | 2019-03-22 | 2019-05-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-22 | 2019-05-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-03-22 | 2019-05-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-22 | 2019-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-22 | 2019-05-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-03-22 | 2019-05-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-03-18 | 2019-04-12 | N |
