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Sagecrest Nursing And Rehabilitation

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About Sagecrest Nursing And Rehabilitation

General Information

Legal Business NamePinnacle Health Facilities Xxxiii Lp
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareSeptember 27, 1984 (33 years)
Capacity120
Residents95
Percent Occupied79%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityYes
Auto Sprinkler System In Required AreasYes

Ratings for Sagecrest Nursing And Rehabilitation

Sagecrest Nursing And Rehabilitation
was reviewed by Medicare to have a rating of 1 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

October 28, 2016 - 5 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.

September 23, 2016 - 6 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide clean bed and bath linens that are in good condition.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential 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.
DFewPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential 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 InspectionTry to resolve each resident's complaints quickly.

July 12, 2016 - 9 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaintMaintain comfortable and safe temperature levels.
DFewPotential for HarmComplaintDevelop 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.

June 1, 2016 - 10 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmComplaintEnsure that residents are safe from serious medication errors.
ESomePotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmComplaintReasonably accommodate the needs and preferences of each resident.
ESomePotential for HarmComplaintProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmComplaintDevelop 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 HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintEnsure 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.
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaintGive the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.
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.
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

February 4, 2016 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$8,750 fine
FManyPotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
FManyPotential for HarmHealth InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmHealth InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
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 InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
FManyPotential for HarmHealth InspectionEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
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 InspectionEnsure that residents are safe from serious medication errors.
ESomePotential for HarmHealth InspectionMake sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.
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 InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
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.
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 InspectionEnsure 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.
DFewPotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionConduct initial and periodic assessments of each resident's functional capacity.
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 InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.

November 9, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

August 21, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHave enough backup water supply for essential areas of the nursing home.
ESomePotential for HarmHealth InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
DFewPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.

June 13, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$8,000 fine
KSomeImmediate JeopardyComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
JFewImmediate JeopardyComplaintProvide food in a way that meets a resident's needs.
JFewImmediate JeopardyComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
JFewImmediate JeopardyComplaintDevelop 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.
FManyPotential for HarmComplaintSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
GFewActual HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmComplaintTry to resolve each resident's complaints quickly.
ESomePotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.
ESomePotential for HarmComplaintMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
ESomePotential for HarmComplaintProvide housekeeping and maintenance services.
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Sagecrest Nursing And Rehabilitation 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 40min
2hr 20min
ReportedExpected
CNA
40min
35min
ReportedExpected
LPN
25min
1hr
ReportedExpected
RN
3hr 45min
3hr 55min
ReportedExpected
Total Nursing

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

Quality Measures for Long Stay Residents

84.4%
92.4%
92.4%
92.4%
90.7%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
77.0%
84.1%
100.0%
97.6%
82.2%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
45.2%
36.0%
36.0%
14.8%
42.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of low risk long-stay residents who lose control of their bowels or bladder
20.0%
20.3%
24.0%
19.5%
18.9%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who received an antianxiety or hypnotic medication
36.6%
24.4%
30.9%
27.6%
21.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents whose ability to move independently worsened
18.3%
16.5%
13.6%
18.5%
17.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who received an antipsychotic medication
32.9%
21.1%
23.3%
21.3%
19.9%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents whose need for help with daily activities has increased
16.7%
19.0%
17.0%
14.3%
11.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who self-report moderate to severe pain
3.5%
0.0%
2.4%
1.2%
7.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who lose too much weight
7.9%
5.3%
6.7%
1.9%
6.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of high risk long-stay residents with pressure ulcers
1.2%
3.9%
1.4%
0.0%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who have depressive symptoms
1.2%
0.0%
1.2%
0.0%
3.0%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents with a urinary tract infection
4.6%
4.9%
4.8%
3.6%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents experiencing one or more falls with major injury
5.2%
5.0%
1.2%
0.0%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents with a catheter inserted and left in their bladder
2.3%
0.0%
1.2%
0.0%
0.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

58.0%
60.2%
70.1%
70.3%
68.3%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
61.6%
63.3%
63.3%
63.3%
67.1%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
61.3%
64.5%
-
-
61.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
30.0%
35.3%
22.9%
25.0%
23.7%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
4.8%
4.2%
2.7%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.0%
1.4%
1.2%
1.5%
Q4 2015Q1 2016Q2 2016Q3 2016NM
Percentage of short-stay residents with pressure ulcers that are new or worsened