LADERA CENTER

Nursing Home Inspector

5901 OURAY ROAD NW
ALBUQUERQUE, NM 87120
Bernalillo County
Phone: 505-836-0023
Provider Number: 325037
Last Inspection: 07/31/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 110
Beds Available: 10
Percent Occupancy: 92%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

57

Facility
32

County
37

NM
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

57

2017
0

2016
45

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

7/31/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Widespread : Potential 4 8/23/2017
 
Failed To: Let residents voice a complaint or grievance without being treated differently or badly. Pattern : Minimal 4 8/23/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 8/23/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/11/2017
 
Failed To: Maintain comfortable sound levels. Isolated : Minimal 3 8/23/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 8/23/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 8/23/2017
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 8/23/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 10/11/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 8/23/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 10/11/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 8/23/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 8/23/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Immediate 6 8/23/2017
 

6/30/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 7/24/2015
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Actual 4 8/13/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 7/24/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/18/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 7/28/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 7/31/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 7/31/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 7/31/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 7/29/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Immediate 7 6/30/2015
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 7/29/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/22/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Minimal 3 10/11/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/11/2017
 

5/19/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 6/15/2017
 

10/26/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Actual 4 11/17/2016
 

6/23/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 8/5/2016
 

8/28/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 9/28/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 8/18/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 9/28/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NM State Avg
Number of Residents 110 96.68 77.72
Registered Nurses 0.56 0.70 0.82
Licensed Practical / Vocational Nurses 0.68 0.55 0.49
Certified Nursing Assistants 2.25 2.21 2.18
Total Staff Hours 3.49 3.45 3.50

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NM State Avg%
of high risk long-stay residents with pressure ulcers 8 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 90 89 84
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 92 90 92
of long-stay residents experiencing one or more falls with major injury 2 2 3
of long-stay residents who have depressive symptoms 2 4 4
of long-stay residents who lose too much weight 10 7 7
of long-stay residents who received an antianxiety or hypnotic medication 21 16 18
of long-stay residents who received an antipsychotic medication 12 14 16
of long-stay residents who self-report moderate to severe pain 7 8 10
of long-stay residents who were physically restrained 2 0 0
of long-stay residents whose ability to move independently worsened 25 23 21
of long-stay residents whose need for help with daily activities has increased 21 20 18
of long-stay residents with a catheter inserted and left in their bladder 2 2 2
of long-stay residents with a urinary tract infection 1 1 3
of low risk long-stay residents who lose control of their bowels or bladder 41 48 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 85 74 69
of short-stay residents who had an outpatient emergency department visit 11 11 13
of short-stay residents who made improvements in function 69 64 64
of short-stay residents who newly received an antipsychotic medication 2 1 2
of short-stay residents who self-report moderate to severe pain 9 20 23
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 84 70 69
of short-stay residents who were rehospitalized after a nursing home admission 25 20 20
of short-stay residents who were successfully discharged to the community 54 59 53
of short-stay residents with pressure ulcers that are new or worsened 0 0 1