GOOD SAMARITAN SOCIETY BETTY DARE

Nursing Home Inspector

3101 NORTH FLORIDA AVENUE
ALAMOGORDO, NM 88310
Otero County
Phone: 575-434-0033
Provider Number: 325061
Last Inspection: 03/15/2017

About the Nursing Home

Number of Beds: 90
Number of Residents: 66
Beds Available: 24
Percent Occupancy: 73%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non 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

 

48

Facility
31

County
37

NM
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

48

2017
27

2016
21

2014

Medicare Ratings

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

 

Details by Inspection Date

3/15/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 4/3/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/3/2017
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 4/3/2017
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 4/3/2017
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 4/3/2017
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 4/3/2017
 
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 1/26/2017
 
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Isolated : Actual 4 1/26/2017
 
Failed To: Send unopened mail from residents and promptly deliver unopened mail to residents. Widespread : Potential 4 4/3/2017
 
Failed To: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Pattern : Minimal 4 4/7/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 4/3/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 4/3/2017
 
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 4/3/2017
 

1/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 3/21/2016
 
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. Widespread : Minimal 5 3/21/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Isolated : Minimal 3 3/21/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 3/21/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 3/21/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 3/21/2016
 
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 : Minimal 3 3/21/2016
 

11/21/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 12/19/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 12/19/2014
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 12/19/2014
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 12/19/2014
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 12/19/2014
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 12/19/2014
 

Complaint Investigation Deficiencies

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

4/1/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 5/27/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 5/27/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 5/27/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 5/27/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NM State Avg
Number of Residents 66 62.67 77.72
Registered Nurses 0.89 0.81 0.82
Licensed Practical / Vocational Nurses 0.52 0.62 0.49
Certified Nursing Assistants 1.90 2.18 2.18
Total Staff Hours 3.31 3.61 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 6 5 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 68 84
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 78 92
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 4 9 4
of long-stay residents who lose too much weight 7 6 7
of long-stay residents who received an antianxiety or hypnotic medication 16 20 18
of long-stay residents who received an antipsychotic medication 33 28 16
of long-stay residents who self-report moderate to severe pain 12 15 10
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 20 20 21
of long-stay residents whose need for help with daily activities has increased 13 15 18
of long-stay residents with a catheter inserted and left in their bladder 2 3 2
of long-stay residents with a urinary tract infection 3 3 3
of low risk long-stay residents who lose control of their bowels or bladder 66 51 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 63 53 69
of short-stay residents who had an outpatient emergency department visit 29 26 13
of short-stay residents who made improvements in function 56 55 64
of short-stay residents who newly received an antipsychotic medication 3 5 2
of short-stay residents who self-report moderate to severe pain 29 31 23
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 71 60 69
of short-stay residents who were rehospitalized after a nursing home admission 18 21 20
of short-stay residents who were successfully discharged to the community 41 38 53
of short-stay residents with pressure ulcers that are new or worsened 1 0 1