VIDA ENCANTADA NURSING & REHAB

Nursing Home Inspector

2301 COLLINS DRIVE
LAS VEGAS, NM 87701
San Miguel County
Phone: 505-425-9362
Provider Number: 325065
Last Inspection: 05/09/2017

About the Nursing Home

Number of Beds: 102
Number of Residents: 82
Beds Available: 20
Percent Occupancy: 80%
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
39

County
37

NM
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

57

2017
53

2016
84

2015

Medicare Ratings

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

 

Details by Inspection Date

5/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Minimal 4 6/30/2017
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 6/30/2017
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 6/30/2017
 
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 6/30/2017
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern : Minimal 4 6/30/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 6/30/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/30/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 6/30/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Minimal 4 6/30/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/30/2017
 
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. Pattern : Minimal 4 6/30/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/30/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 6/30/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 6/30/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 6/30/2017
 

6/8/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. Pattern : Minimal 4 7/11/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 7/11/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 7/11/2016
 
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 7/11/2016
 
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 7/11/2016
 
Failed To: Provide housekeeping and maintenance services. Widespread : Minimal 5 7/11/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Actual 4 7/11/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Actual 5 10/1/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Widespread : Minimal 5 7/11/2016
 
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Widespread : Minimal 5 8/1/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/1/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 10/1/2016
 

3/10/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 5/11/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 5/11/2015
 
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 5/11/2015
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Immediate 6 5/11/2015
 
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 : Immediate 6 5/11/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 5/11/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 5/11/2015
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 5/11/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/11/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 5/11/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 5/11/2015
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 5/11/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 5/11/2015
 
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 5/11/2015
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Isolated : Minimal 3 5/11/2015
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 5/11/2015
 
Failed To: Make sure that doctors visit residents regularly, as required. Isolated : Minimal 3 5/11/2015
 
Failed To: Provide routine and 24-hour emergency dental care for each resident. Widespread : Minimal 5 5/11/2015
 
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. Pattern : Minimal 4 5/11/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 5/11/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 5/11/2015
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Widespread : Minimal 5 5/11/2015
 

Complaint Investigation Deficiencies

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

5/9/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 6/30/2017
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Pattern : Minimal 4 6/30/2017
 

3/23/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/4/2015
 

3/10/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Widespread : Minimal 5 5/11/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NM State Avg
Number of Residents 82 119.50 77.72
Registered Nurses Not Available 0.35 0.82
Licensed Practical / Vocational Nurses Not Available 0.14 0.49
Certified Nursing Assistants Not Available 1.32 2.18
Total Staff Hours Not Available 1.81 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 7 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 65 73 84
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 96 92
of long-stay residents experiencing one or more falls with major injury 1 2 3
of long-stay residents who have depressive symptoms 0 0 4
of long-stay residents who lose too much weight 10 7 7
of long-stay residents who received an antianxiety or hypnotic medication 12 21 18
of long-stay residents who received an antipsychotic medication 7 20 16
of long-stay residents who self-report moderate to severe pain 9 7 10
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 19 16 21
of long-stay residents whose need for help with daily activities has increased 16 15 18
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 0 1 3
of low risk long-stay residents who lose control of their bowels or bladder 44 36 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 69 39 69
of short-stay residents who had an outpatient emergency department visit 16 16 13
of short-stay residents who made improvements in function 73 73 64
of short-stay residents who newly received an antipsychotic medication 3 3 2
of short-stay residents who self-report moderate to severe pain 21 21 23
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 80 47 69
of short-stay residents who were rehospitalized after a nursing home admission 23 23 20
of short-stay residents who were successfully discharged to the community 54 54 53
of short-stay residents with pressure ulcers that are new or worsened 4 4 1