SOMBRILLO NURSING FACILITY (LOS ALAMOS, NM) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	21.6%
New Mexico:	18.0%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	3.2%
State:	7.3%

Percent of long-stay residents who lose too much weight

Here:	17.0%
New Mexico:	9.1%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	4.0%
New Mexico:	3.6%

Percent of long-stay residents with a urinary tract infection

Here:	12.8%
State:	6.9%

Percent of long-stay residents who have depressive symptoms

Here:	6.8%
State:	6.2%

Percent of long-stay residents who were physically restrained

This Nursing Home:	4.2%
New Mexico:	1.7%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	82.9%
New Mexico:	87.6%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	47.9%
New Mexico:	81.5%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	14.3%
New Mexico:	27.1%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	8.6%
New Mexico:	70.6%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	14.1%
State:	67.2%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	10.9%
State:	21.5%

Complaint Deficiency

Did not have a written emergency evacuation plan
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Signs that state that exit doors are to be kept closed
- Harm: Actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Actual harm
- Scope: Few
A properly installed and maintained dumbwaiter or escalator
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident's personal and medical records private and confidential
- Harm: Potential for minimal harm
- Scope: Some
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents are safe from serious medication errors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Put firmly secured handrails on each side of hallways
- Harm: Potential for minimal harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Many
Did not have a written emergency evacuation plan
- Harm: Potential for minimal harm
- Scope: Many
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Other fire safety features required by fire safety codes
- Harm: Potential for minimal harm
- Scope: Many
Back-up procedures in place for a faulty automatic sprinkler system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
- Harm: Actual harm
- Scope: Few
Listen to the resident or family groups or act on their complaints or suggestions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide a safe, clean, comfortable and homelike environment
- Harm: Potential for minimal harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Follow rules about disclosure of ownership requirements or tell the state agency about changes in administrative personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Review or revise the resident's care plan after any major change in a resident's physical or mental health
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests
- Harm: Minimal harm or potential for actual harm
- Scope: Many

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.370
New Mexico:	0.722

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.460
New Mexico:	0.509

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	0.830
New Mexico:	1.227

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.100
State:	0.109

Number Therapy Hours Per Resident Per Day

Here:	0.100
State:	0.113

SOMBRILLO NURSING FACILITY - LOS ALAMOS, NM

Quality Measures

Complaint Deficiency

Staff Information

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