cms_NM: 2

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
2 SANTA FE CARE CENTER 325030 635 HARKLE ROAD SANTA FE NM 87505 2020-01-16 660 E 1 0 WQZY11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop post-discharge plans that focused on residents' individualized discharge goals and needs for 3 (R #'s 1, 2 and 3) of 3 (R #'s 1, 2 and 3) residents reviewed for discharge planning. This deficient practice has the potential to complicate or prevent smooth and safe transitions from the facility to the residents' post-discharge settings. The findings are: Findings for R #1: [NAME] Record review of R #1's admission record revealed that R #1 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed that R #1 was discharged home on[DATE]. C. Record review of the facility's Discharge Summary and Plan policy revised (MONTH) (YEAR) stipulates: 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT (interdisciplinary team - the group of persons who develop a individual program plan to meet the resident's needs for services.) will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. 6. The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 8. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. 9. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 10. Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. Data used in helping the resident select an appropriate facility includes the receiving facility's: a. standardized patient assessment data; b. quality measure data; and c. data on resource use. 11. The resident or representative (sponsor) should provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. 12. A member of the IDT will review the final post-discharge plan with the resident and family at least twentyfour (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. D. Record review revealed no documented Post-Discharge Plan (a plan developed by a care planning/interdisciplinary team with the assistance of the resident and/or the residents' family) was implemented for R #1. E. On 01/14/20 at 9:25 am, during an interview, the Social Services Director reported that they do not conduct Discharge Meetings unless the resident and/or family requests them, but they do discuss upcoming discharges at the weekly UR (utilization review) meetings, which occur every Tuesday; however they do not take meeting minutes (notes) or document the meetings anywhere. The SSD reported that staff members from the following departments participate in the UR meetings: therapy, business office, MDS (minimum data set), social services, medical records, nursing and sometimes the Administrator. F. On 01/14/20 at 10:50 am, during an interview, the Director of Nursing reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #1; however all discharges are discussed during the Daily Stand-Up Meeting and the resident names are documented under the Discharges Yesterday or Planned Discharges This Week sections of the Daily Stand-Up Meeting form. Findings for R #2: [NAME] Record review of R #2's admission record revealed that R #2 was admitted to the facility on [DATE]. H. Record review of R #2's progress notes revealed that R #2 was discharged home on[DATE]. I. Record review revealed no detailed Post-Discharge Plan was implemented for R #2. [NAME] On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #2. Findings for R #3: K. Record review R #3's admission record revealed that R #3 was admitted to the facility on [DATE]. L. Record review R #3's progress notes revealed that R #3 was discharged home on[DATE]. M. Record review revealed no detailed Post-Discharge Plan was implemented for R #3. N. On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #3. 2020-09-01