Inspection Results » Santa Fe Lodge

Health Inspection on February 15, 2019 ^[1]

1. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Keep all essential equipment working safely. (Corrected 2019-03-18)
   • 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. (Corrected 2019-03-18)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-03-18)

2. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Implement a program that monitors antibiotic use. (Corrected 2019-03-18)
   • 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 ne (Corrected 2019-03-18)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-03-18)
   • Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. (Corrected 2019-03-18)
   • 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. (Corrected 2019-03-18)

3. Pattern: No actual harm with potential for minimal harm

   • 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. (Corrected 2019-03-18)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2019-03-18)
   • Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. (Corrected 2019-03-18)