Sandia Ridge Center

In the surveyor’s words

From the most serious findings on record at Sandia Ridge Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF580Jan 13, 2023

  Based on interviews, record review, and review of facility policy, the facility failed to immediately notify/report to the physician a change of condition for two residents (Resident (R)75 and R53) out of 28 sampled residents. The facility's failed practice likely resulted in R75's death at the facility on [DATE]. Findings include: Review of facility-provided policy titled Change of Condition, [DATE], revealed .A Center must immediately inform .the patient's physician a significant change in patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status) in either life-threatening conditions or clinical complications .to provide appropriate and timely information relevant to the patient's condition . 1. […]

• Immediate jeopardy, widespreadF610Jan 13, 2023

  Based on interviews, record review, and policy review, the facility failed to ensure residents were protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and failed to have evidence that all alleged violations were thoroughly investigated for one resident (Resident (R) 25) out of one resident reviewed for abuse in a total sample of 28 residents. Specifically, the two alleged perpetrators, Certified Nursing Assistant (CNA)1 and CNA2 were not removed from the facility but were reassigned and remained in the facility working with other residents the evening of the alleged abuse and the Administrator failed to thoroughly investigate conflicting verbal and written statements by the CNAs. […]

• Immediate jeopardy, widespreadF684Jan 13, 2023

  Based on interviews, record review, and review of the facility's policy, the facility failed to complete a change of condition assessment when the nursing staff had difficulty arousing with a sternal rub (A sternal rub is the application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimulit) through the night and into the next day for one resident (Resident (R) 75) out of a total sample of 28 residents. The facility's failed practice likely resulted in R75's death at the facility on [DATE]. […]

• Actual harm, isolatedF600Apr 12, 2023

  Based on record review and interview the facility failed to prevent resident to resident abuse for [R #1] of 3 [R #1, R #2 and R #9] residents reviewed for sexual abuse by R #2 sexually assaulting R #1. This deficient practice likely resulted in psychosocial harm to residents. The findings are. A. Record review of the facesheet for R #1 indicated the following, R #1 was admitted on [DATE] for the following Diabetes Mellitus Type 2 (your body doesn't use insulin properly) right carotid artery occlusion (occurs when fatty deposits (plaques) clog the blood vessels that deliver blood to your brain and head), major depressive disorder (clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in… […]

• Actual harm, isolatedF740Apr 12, 2023

  Based on record review, observation, and interview, the facility failed to provide the necessary behavioral health services for 1 (R #3) of 1 (R #3) resident reviewed. This deficient practice likely resulted in worsening anxiety and depression for R #3. The findings are: A. Record review of R #3's face sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses: recurrent major depressive disorder with severe psychotic symptoms (a medical condition that causes you to experience psychotic symptoms plus the sadness and hopelessness associated with depression such as seeing, hearing, smelling, or believing things that aren't real), unspecified psychosis (a condition that affects the way your brain processes information; it causes you to lose touch with reality)… […]