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Good Samaritan Society - Manzano Del Sol

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About Good Samaritan Society - Manzano Del Sol

General Information

Legal Business NameThe Evangelical Lutheran Good Samaritan Society
Ownership TypeNon Profit - Church Related
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareOctober 1, 1992 (25 years)
Capacity117
Residents80
Percent Occupied68%
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 Good Samaritan Society - Manzano Del Sol

Good Samaritan Society - Manzano Del Sol
was reviewed by Medicare to have a rating of 4 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

May 10, 2016 - 11 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
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 InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
ESomePotential for HarmHealth InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
ESomePotential for HarmHealth InspectionProtect each resident from mistreatment, neglect and misappropriation of personal property.
ESomePotential for HarmHealth Inspection1) 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.
ESomePotential for HarmHealth InspectionDevelop 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.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential 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.

May 22, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 76 days
---Fine$16,153 fine
LManyImmediate JeopardyHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
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 InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmHealth InspectionReasonably accommodate the needs and preferences of each resident.

June 30, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,170 fine
GFewActual HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaint+InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmComplaint+InspectionConduct initial and periodic assessments of each resident's functional capacity.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Good Samaritan Society - Manzano Del Sol 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 50min
2hr 20min
ReportedExpected
CNA
30min
35min
ReportedExpected
LPN
1hr 10min
1hr
ReportedExpected
RN
4hr 35min
3hr 60min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

95.2%
90.5%
90.5%
90.5%
90.7%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
45.0%
47.5%
68.9%
87.5%
82.2%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
52.2%
-
58.8%
69.7%
42.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
* The data for this facility for some quarters is unavailable.
Percentage of low risk long-stay residents who lose control of their bowels or bladder
7.1%
9.3%
8.7%
9.3%
18.9%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who received an antianxiety or hypnotic medication
13.2%
25.1%
17.8%
19.7%
21.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents whose ability to move independently worsened
5.0%
4.9%
4.9%
5.4%
17.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who received an antipsychotic medication
10.3%
5.0%
9.5%
9.8%
19.9%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents whose need for help with daily activities has increased
12.3%
6.8%
5.6%
4.5%
11.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who self-report moderate to severe pain
13.8%
10.0%
5.0%
5.4%
7.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who lose too much weight
2.2%
2.2%
2.3%
0.0%
6.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of high risk long-stay residents with pressure ulcers
0.0%
3.2%
0.0%
0.0%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who have depressive symptoms
0.0%
9.8%
1.7%
3.6%
3.0%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents with a urinary tract infection
0.0%
0.0%
0.0%
3.6%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents experiencing one or more falls with major injury
1.7%
1.6%
3.5%
1.8%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

25.4%
36.4%
52.1%
67.3%
68.3%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
47.4%
40.3%
40.3%
40.3%
67.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
54.0%
46.7%
53.5%
62.2%
61.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who made improvements in function
45.5%
40.5%
33.8%
32.3%
23.7%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
2.1%
2.8%
2.0%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.9%
1.0%
0.3%
1.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents with pressure ulcers that are new or worsened