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SOMBRILLO NURSING FACILITY

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SOMBRILLO NURSING FACILITY VS
Nursing Homes USA
General
City LOS ALAMOS   0% Nursing Homes USA have LOS ALAMOS
State attribute explanation NM   0.5% Nursing Homes USA have NM
Street 1011 SOMBRILLO COURT  
Zip Code 87544  
Phone 5056624300  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
66 
108.94
Total Number of Residents
58 
91.25
Percent of Occupied Beds
88 %
83.65 %
Health Survey Date 8/19/2011  
Fire Survey Date 8/2/2011  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership Non Profit - Corporation  18.7% Nursing Homes USA have Non profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies
7.48
Staff Information
Number of Residents
58 
91.38
Number of RN Hours Per Resident Per Day
0.37 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.46 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
0.83 
1.59
Number of CNA Hours Per Resident Per Day
0.1 
5.49
Number Therapy Hours Per Resident Per Day
0.1 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Listen To The Resident Or Family Groups Or Act On Their Complaints Or Suggestions.
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Give Each Resident A Notice Of Rights, Rules, Services And Charges. Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items And Services Medicaid Covers And Which The Resident Must Pay For.
survey Date: 08/03/2010
date Of Correction: 08/10/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 4
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Follow Rules About Disclosure Of Ownership Requirements Or Tell The State Agency About Changes In Administrative Personnel.
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%.
survey Date: 08/03/2010
date Of Correction: 09/15/2010 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
18.6 (65.5) %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who lose too much weight
14.3 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.7 %
15.63 %
Percent of long-stay residents with a urinary tract infection
20.9 %
13.46 %
Percent of long-stay residents who have depressive symptoms
75.2 %
28.38 %
Percent of long-stay residents who were physically restrained
4.5 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
23.3 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
13.6-28 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
18.3 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication 2.6 / 3 % 
Percent of long-stay residents experiencing one or more falls with major injury
75.2 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
21.1 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
1.4 %
23.70 %
Percent of long-stay high-risk residents with pressure ulcers 10.3:1 % 
Percent of long-stay residents who lose too much weight
13 %
8.50 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.4 %
10.65 %
Percent of long-stay residents with a urinary tract infection
17.5 %
9.58 %
Percent of long-stay residents who have depressive symptoms
75.2 %
19.86 %
Percent of long-stay residents who were physically restrained
5.7 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
75.2 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
23.1 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
14 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
26.2 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
17.5 %
17.34 %

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