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Sombrillo Nursing Facility

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About Sombrillo Nursing Facility

General Information

Legal Business NameLos Alamos Retirement Center, Inc.
Ownership TypeNon Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareOctober 7, 1991 (25 years)
Capacity66
Residents52
Percent Occupied79%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Sombrillo Nursing Facility

Sombrillo Nursing Facility
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of New Mexico Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

June 4, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
LManyImmediate JeopardyHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionMake sure that special or therapeutic diets are ordered by the attending doctor.
ESomePotential for HarmHealth InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionEnsure 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.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
ESomePotential for HarmHealth InspectionProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
ESomePotential for HarmHealth InspectionMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
ESomePotential for HarmHealth InspectionConduct initial and periodic assessments of each resident's functional capacity.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmHealth InspectionProvide resident groups or resident family groups with private space to meet.
CManyPotential for Minimal HarmHealth InspectionProvide housekeeping and maintenance services.
DFewPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmHealth InspectionProvide or obtain dental services for each resident.
DFewPotential for HarmHealth InspectionEnsure residents maintain acceptable nutritional status.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionGive notice to the resident before a room or roommate change.
DFewPotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmHealth InspectionEnsure that residents are safe from serious medication errors.
DFewPotential for HarmHealth InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.

May 19, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionOther fire safety features required by fire safety codes.

June 19, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmComplaint+InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmComplaint+InspectionEnsure 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.
ESomePotential for HarmFire Safety InspectionProperly protected cooking facilities.
ESomePotential for HarmFire Safety InspectionAn externally vented heating system.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
DFewPotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .

May 30, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

April 25, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,500 fine
HSomeActual HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
HSomeActual HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaint1) 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.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Sombrillo Nursing Facility require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 35min
2hr 15min
ReportedExpected
CNA
15min
30min
ReportedExpected
LPN
35min
50min
ReportedExpected
RN
3hr 25min
3hr 35min
ReportedExpected
Total Nursing

This facility also provides approximately 55min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
98.1%
98.1%
87.8%
Q1 2015Q2 2015Q3 2015NM
Assessed and Appropriately Given the Seasonal Influenza Vaccine
97.7%
100.0%
100.0%
78.9%
Q1 2015Q2 2015Q3 2015NM
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
43.9%
Q1 2015Q2 2015Q3 2015NM
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
13.6%
12.8%
11.1%
16.3%
Q1 2015Q2 2015Q3 2015NM
Received an Antipsychotic Medication
46.2%
9.3%
10.5%
18.2%
Q1 2015Q2 2015Q3 2015NM
Need for Help with ADLs has Increased
-
10.7%
3.9%
9.8%
Q1 2015Q2 2015Q3 2015NM
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
6.8%
10.6%
4.4%
6.8%
Q1 2015Q2 2015Q3 2015NM
Lose Too Much Weight
-
-
-
6.0%
Q1 2015Q2 2015Q3 2015NM
* The data for this facility for some quarters is unavailable.
High Risk Residents With Pressure Ulcers
2.4%
0.0%
0.0%
3.0%
Q1 2015Q2 2015Q3 2015NM
Have Depressive Symptoms
2.3%
4.3%
2.2%
4.3%
Q1 2015Q2 2015Q3 2015NM
With a Urinary Tract Infection
13.6%
6.4%
6.7%
3.8%
Q1 2015Q2 2015Q3 2015NM
Experiencing One or More Falls with Major Injury
0.0%
1.8%
2.3%
3.3%
Q1 2015Q2 2015Q3 2015NM
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015NM
Were Physically Restrained

Quality Measures for Short Stay Residents

77.0%
90.7%
97.6%
69.5%
Q1 2015Q2 2015Q3 2015NM
Assessed and Appropriately Given the Pneumococcal Vaccine
85.0%
85.0%
85.0%
68.2%
Q1 2015Q2 2015Q3 2015NM
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
9.8%
8.3%
17.9%
24.2%
Q1 2015Q2 2015Q3 2015NM
Self Report Moderate to Severe Pain
0.0%
0.0%
3.1%
2.3%
Q1 2015Q2 2015Q3 2015NM
Newly Received an Antipsychotic Medication
0.8%
0.0%
2.0%
1.3%
Q1 2015Q2 2015Q3 2015NM
With Pressure Ulcers That Are New or Worsened