Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Fe Lodge during CMS and state inspections, most recent first.
Psychotropic Medications Given Without Timely Informed Consent: Two residents received psychotropic meds without timely IC. One resident with dementia and anxiety had Quetiapine restarted after it had been discontinued, but the only IC was dated later and there was no documentation the RP was informed when the drug was restarted. Another resident with anxiety, depression, and schizophrenia received Lexapro, trazodone, and olanzapine before the ICs were obtained, and the DON noted there was no IC showing the olanzapine dosage change before the current consent.
Psychotropic Medication Monitoring and Indication Deficiencies: The facility failed to follow its psychotropic med policy for two residents. One resident on mirtazapine for depression had no documented side effect monitoring in the MAR despite a care plan intervention to observe and document side effects. Another resident had Seroquel ordered for agitation, but the record lacked documentation of a specific target behavior or behavior monitoring to support the restart and ongoing use of the med; staff interviews showed the resident was generally confused and sometimes combative during ADLs, but no behavior tracking was documented.
A resident at high fall risk with dementia and metabolic encephalopathy had a bed-exit alarm ordered for use while in bed, but staff found the alarm inside a closed bedside drawer when the resident fell after trying to get up. Loud music was playing near the room, and staff stated the alarm should have been placed where it could be heard more clearly. In a separate incident, a resident with impaired vision and severely impaired cognition had an unattended spray bottle labeled bleach left on the bedside table, and staff stated cleaning chemicals should not be left with residents.
A resident with FTT, AKF, weight loss, and a G-tube did not receive tube feeding and water flushes as ordered. Staff observed the TF pump set incorrectly for flushes, and later the feeding was stopped early after an LPN relied on the eMAR turning yellow instead of the physician order, resulting in less formula than ordered.
Two residents were found to have unnecessary medication issues. One resident with a UTI and urinary catheter received Levaquin without documented McGeer criteria being met, and later continued on Ciprofloxacin even after urine culture results showed resistance. Another resident with dementia and anxiety was restarted on Seroquel for agitation without documented behavior evidence or behavior monitoring, and the order did not specify the behavior being treated.
A refrigerator at a nurse's station used to store residents' food from home was observed with debris on two shelves and dried brown liquid on the bottom and side shelves on consecutive days. The CDM stated the refrigerator was not clean, and RN 1 later stated it needed to be wiped. The facility policy required refrigerators and freezers to be kept clean, free of debris, and disinfected on a scheduled basis.
A resident with a history of sepsis and UTI received multiple antibiotic orders, but the IPN did not complete McGeer surveillance for Levaquin and there was no documented evidence the resident met criteria for its use or that the prescriber was notified. The resident also continued to receive Ciprofloxacin even after the urine C&S showed the bacteria were resistant, and there was no documented evidence the ordering physician was informed of the resistance results. The facility’s antibiotic stewardship policy required lab results and the resident’s clinical status to be communicated to the prescriber to determine whether therapy should be started, continued, modified, or discontinued.
Failure to Send Discharge Notice to Ombudsman: The facility did not send a resident's Notice of Proposed Transfer and Discharge to the State LTC Ombudsman after discharge. The resident had COPD and schizoaffective disorder, lacked capacity to make decisions per H&P, and had moderately impaired cognitive skills on the MDS. The SSD stated the facility normally faxed discharge notifications to the Ombudsman, but this resident's notice was not sent, despite the facility policy requiring a copy be sent to the Ombudsman.
A resident’s MDS did not accurately reflect a depression diagnosis even though the admission record listed depression, anxiety, and dementia, and the resident had an active order for Mirtazapine for depression with poor oral intake. The MDS nurse acknowledged the discrepancy and stated the resident should have been marked as having depression because the resident was actively receiving antidepressant medication.
Improperly Prepared Liquidized Diet: A resident with dementia and dysphagia was ordered a liquidized texture diet with liquidized pureed items for all meals, but during lunch observation the tray included a bowl of mashed food that did not meet the ordered consistency. CNA assistance, DON testing, and RRD input confirmed the food was not prepared in the form ordered, and staff stated the item was a mistake.
Staff interviews and record review showed that multiple CNAs and an LVN did not know who the facility’s Abuse Coordinator was or which external agencies must receive abuse allegations within the required two-hour timeframe. The DSD stated that the Administrator is the Abuse Coordinator and that all staff are expected to know to report suspected abuse to the Administrator, who then reports to the state survey agency, APS, law enforcement, and the Ombudsman. The facility’s written abuse prevention policy confirms these responsibilities and timelines, yet interviewed staff were unable to identify the Abuse Coordinator or the mandated reporting entities.
A resident with schizophrenia, impulse disorder, and HTN, who lacked decision-making capacity, allegedly yelled "rape" when a CNA entered the room. The CNA delayed reporting the allegation to an LVN, and the LVN further delayed notifying the DON and did not immediately inform the administrator. As documented on an SBAR form, the allegation of physical and sexual abuse by staff was not reported to law enforcement, the Ombudsman, or the state agency until several hours later, exceeding the facility’s policy requirement to report abuse allegations within two hours.
A resident with dementia, impaired cognition, gait and mobility issues, and a known fall risk experienced a fall that triggered an alarm, after which an LVN found the resident on the floor with an abrasion and notified the primary nurse. Despite facility policy requiring prompt assessment, documentation of a change of condition (COC), and physician notification for injuries and falls, no post-fall assessment, COC documentation, or MD notification was found in the record. The DON and nursing staff later confirmed that a fall is considered a change of condition and that the charge nurse was responsible for completing the COC, but this was not done.
A resident with severe cognitive impairment was placed on bed and wheelchair alarms and started on Lexapro and Remeron without documented informed consent from the resident or their representative. Staff confirmed that required consents were not obtained prior to implementing these interventions, contrary to facility policy.
The facility did not ensure that executed advance directives were obtained and maintained in the medical records for three residents, despite documentation indicating that these legal documents existed. For two residents with severe cognitive impairment and one with intact cognition, the actual ADs were missing from their files, and the Social Services Assistant confirmed the documents could not be found. Facility policy required that ADs be readily retrievable, but this was not followed.
Three residents with significant medical conditions did not have weekly weights obtained or documented as required by physician orders and facility policy. Staff responsible for weighing residents lacked access to the electronic record system and relied on others to enter data, resulting in missing documentation for required weekly weights. This failure occurred despite clear orders and care plans indicating the need for close monitoring due to recent weight loss.
Surveyors found that food items in the kitchen walk-in refrigerator, including sliced cheese, a jar of pickles, and whipping cream, were not labeled with required open or received dates. Both the Certified Dietary Manager and Registered Dietitian confirmed that labeling is necessary to track food quality and freshness, and facility policy requires all items to be properly dated and labeled.
Two residents with significant medical and mental health conditions signed binding arbitration agreements that did not include a provision allowing them or their representatives to communicate with federal, state, or local officials. The Admission Coordinator confirmed the omission during interviews and record reviews.
Multiple infection control lapses were observed, including unlabeled and improperly stored personal care items in a shared restroom, a resident with severe cognitive impairment independently accessing communal drink pitchers, uncleaned dryer lint traps, soiled bed linens with suspected fecal matter, and a used cup left on a hallway handrail. Staff interviews confirmed these practices did not follow facility policy and posed risks for cross-contamination.
A resident with severe cognitive impairment and mental health conditions was left exposed while sitting in a shower chair, with privacy curtains only partially drawn and the room door open as a CNA prepared for care. This exposure was visible to others in the hallway, and both the CNA and RN Supervisor acknowledged the lapse in maintaining the resident's privacy and dignity, contrary to the care plan and facility policy.
A resident with severe cognitive impairment and multiple mental health diagnoses was observed sitting in a wheelchair with the call light secured to the bed's grab bar, out of reach. Staff confirmed the call light was not accessible, despite facility policy requiring call lights to be within reach for all residents.
A resident was readmitted with multiple diagnoses and a new order for Depakote to treat bipolar disorder, but the facility failed to update the MDS and admission records to reflect the new diagnosis. Despite documentation in physician orders and progress notes, the bipolar disorder was not included in the resident's official records, contrary to facility policy requiring current and detailed health records.
A resident with a history of traumatic subdural hemorrhage, seizures, and hypertension was admitted and had a positive PASARR Level I screening for SMI, but the facility did not complete or document the required Level II evaluation, as confirmed by interviews and record review.
A resident was readmitted with a new diagnosis of bipolar disorder, but the facility did not update the MDS or develop a care plan to address this condition. Interviews confirmed that staff were aware a care plan was needed for the new diagnosis, but it was not completed, contrary to facility policy requiring care plan updates after significant changes or hospital readmissions.
The facility did not meet the required minimum of 80 square feet per resident in multiple-occupancy rooms, as shown by facility records and room measurements. Despite a waiver request and staff reporting no issues providing care in the available space, the documented room sizes for 20 rooms were below regulatory standards.
A resident with dementia and major depressive disorder eloped from an LTC facility due to inadequate supervision. The resident left through an exit door that was not properly monitored or secured during mealtime, as staff were occupied with feeding other residents. The resident was found with a skin tear upon return. Facility policy emphasized continuous supervision to prevent such incidents, which was not followed.
The facility failed to maintain an acceptable temperature range, affecting several resident rooms, a dining room, and a hallway. The air conditioning unit malfunctioned, leading to temperatures exceeding the facility's acceptable range. The Director of Nursing acknowledged the issue, and the Maintenance Director confirmed the malfunction, stating that the HVAC technician was working on repairs. The facility's policy emphasized maintaining comfortable and safe temperatures, which was not adhered to during the malfunction.
Psychotropic Medications Given Without Timely Informed Consent
Penalty
Summary
The facility failed to ensure residents and/or their responsible parties were informed in advance of the risks and benefits of psychotropic medications for two residents. For one resident with diagnoses including dementia and anxiety disorder, Quetiapine (Seroquel) had been discontinued on 10/3/2025, but it was restarted on 3/26/2026 as 25 mg twice daily for agitation. The resident’s record showed severe cognitive deficit on the 4/7/2026 MDS and maximal assistance needed for oral hygiene, toileting hygiene, and personal hygiene. During review of informed consent forms on 5/6/2026, the only consent found for Quetiapine was dated 4/26/2026, after the medication had already been restarted. The record review and interview showed no documentation that the resident’s responsible party was informed when Quetiapine was restarted. The MDSN stated the hospice physician restarted the medication after it had been discontinued and that informed consent needed to be completed because it was a patient right to be notified of new medications, especially psychotropic medications. The progress notes reviewed for 3/1/2026 through 3/31/2026 did not show behavior supporting the restart or notification of the responsible party. For another resident with diagnoses including anxiety disorder, depression, and schizophrenia, the MAR showed Lexapro 10 mg daily, trazodone 50 mg at bedtime, and olanzapine 5 mg twice daily were administered before the related informed consents were obtained. The resident’s H&P stated the resident had capacity to understand and make decisions, while the 1/26/2026 MDS showed moderately impaired cognitive skills for daily decision making. The psychotherapeutic drug consents were dated 3/25/2026, and the DON stated the resident had received these medications before the consents were obtained and that there was no consent showing the olanzapine dosage change before the current consent. The facility policy stated no psychotherapeutic medication was to be administered prior to informed consent obtained by the prescriber.
Psychotropic Medication Monitoring and Indication Deficiencies
Penalty
Summary
The facility failed to follow its psychotherapeutic medications policy for two residents. For one resident with depression, anxiety, and dementia, the record showed an order for mirtazapine 7.5 mg at bedtime for depression manifested by poor oral intake of less than 50% of meals. The care plan included an intervention to observe for side effects and document them per psychotropic policy, but during review of the MAR with the DON, there was no side effect monitoring documented for the mirtazapine. The DON stated side effect monitoring was important to know whether the resident experienced undesirable effects while on the medication. For another resident with dementia and anxiety disorder, the record showed quetiapine had been discontinued and later restarted, with an active order for Seroquel 25 mg twice daily for agitation. Review of the resident’s progress notes and change-of-condition documentation showed no documentary evidence of behaviors that would support restarting Seroquel. The MDS Nurse stated the medication was restarted when the resident was placed on hospice care, but also stated there was no record of monitoring behaviors for the use of Seroquel in the resident’s MAR for March, April, and May 2026. During interviews, staff described the resident’s baseline as awake, confused, and sometimes attempting to get up, and one CNA stated the resident was combative during ADLs and would push and pinch staff. The DON stated the behavior needed to be specific so staff could monitor it, and the facility’s psychotherapeutic medication policy required a proper diagnosis supporting the drug order, a specific behavior being monitored every shift, and monitoring of side effects on medication sheets. The record review and staff interviews showed these requirements were not documented for the two residents.
Bed Alarm Placed in Drawer and Bleach Bottle Left at Bedside
Penalty
Summary
Resident 23 was admitted with diagnoses including dementia and metabolic encephalopathy and was identified as a high fall risk. The resident’s record included an order and care plan intervention to apply a tab/sensor pad alarm when the resident was in bed to alert staff for unassisted transfer, with the charge nurse to check proper placement and function. On 5/5/2026, staff observed loud music playing near the resident’s room, and when the resident was found on the floor after attempting to get up, the bed alarm was sounding but had been placed inside a closed drawer in a bedside table rather than in a location where staff could easily hear it. The MDS nurse stated the alarm should not have been in the drawer because it affected the ability to hear it, and the nurse stated the alarm could have been heard more prominently if it had not been placed there. Resident 23’s change in condition form documented that the resident had been in bed with the tab alarm in proper placement earlier that morning. During interview, the MDS nurse stated the resident was seen standing and falling to the floor, and that the alarm was heard only after entering the room. A CNA stated the resident would try to get up frequently and that if the alarm was inside the drawer, the sound would not be the same. A concurrent observation confirmed the alarm was inside the closed drawer, and the MDS nurse stated it needed to be outside the drawer so staff could hear it when activated. Resident 34 had diagnoses including paranoid schizophrenia, bipolar disorder, and obsessive-compulsive personality disorder, and the care plan identified impaired visual functioning related to cataracts with an intervention to provide a safe environment free of hazards. The resident’s MDS indicated severely impaired cognition and need for partial/moderate assistance with toilet and personal hygiene. During observation in the resident’s room, a spray bottle labeled bleach was left unattended on the bedside table while the resident was in bed. A CNA stated it was not good for the bottle to be left there and that the resident could get bleach on themselves or drink it. The maintenance supervisor stated cleaning bottles should be placed back on the cart and locked after use, and that housekeepers should not leave cleaning bottles with residents.
Failure to Provide Ordered Tube Feeding and Water Flush
Penalty
Summary
The facility failed to ensure Resident 13 received the ordered amount of water flush and enteral feeding via G-tube. Resident 13 was admitted and later readmitted with diagnoses including adult failure to thrive and acute kidney failure. The MDS dated 4/19/2026 indicated the resident rarely or never could express ideas and wants, sometimes understood verbal content, had weight loss of 5% or more, and was on a feeding tube. During an observation on 5/6/2026, the TF pump was off, a full container of Glucerna 1.2 and a full bag of water were hanging, and the pump setting showed flush at 30 ml every 20 hours. The DON stated the physician order required 30 ml of flush every hour to provide 600 ml of water in 20 hours, and that the pump setting meant the resident would receive less hydration than ordered. During another observation on 5/8/2026, Resident 13 was awake in a Geri chair and there was no TF running and no enteral feeding bag hanging. Review of physician orders showed Glucerna 1.2 at 45 ml/hr for 20 hours, with feeding to stop at 10 AM or when the dose was met. RN 1 stated the feeding had been turned off because the dose was completed, and the history showed 802 ml had been given in 1 day instead of the ordered 900 ml. LVN 3 stated the feeding was stopped because the eMAR had turned yellow and was thought to mean the feeding was complete. The regional RD and DON stated the nurses needed to follow the physician order to provide the required caloric intake. The resident's weight log showed a weight of 104 lb on readmission, then 102 lb on 4/28/2026 and 102 lb on 5/4/2026.
Unnecessary Antibiotic and Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary drugs. For one resident with diagnoses including sepsis and UTI, the record showed urine culture results were released and antibiotics were ordered, but the Infection Prevention Nurse stated there were no notes showing communication with the ordering physician that McGeer’s criteria for a UTI had not been met for Levaquin. The resident also had a urinary catheter, and the IPN stated the McGeer’s Surveillance Data for UTI with Indwelling Catheter was not completed for the Levaquin order. The facility’s process was described as licensed nurses notifying the IPN of new antibiotic orders so the IPN could determine whether McGeer’s criteria were met. The same resident later had a urine culture collected that identified two bacteria resistant to Ciprofloxacin, yet the Medication Administration Record showed Ciprofloxacin was administered for several days after those results were available. The IPN stated there was no communication to the ordering physician about the resistance results and the resident continued to receive Ciprofloxacin. The Director of Nursing stated that administering antibiotics to a resident resistant to the antibiotic would not be effective in treating the UTI. For another resident with dementia and anxiety disorder, the record showed Quetiapine was restarted and ordered for agitation, but the MDS Nurse stated there was no documentary evidence of behaviors that required the medication to be restarted. The MDS Nurse also stated there was no record of behavior monitoring for the use of Seroquel, and the DON stated the behavior needed to be specific so staff could monitor it. The facility policy on unnecessary medication required adequate indication and adequate monitoring for psychotropic medications.
Unsanitary Refrigerator Used for Residents' Food From Home
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices at one nurse's station where residents' food from home was stored in a refrigerator. During a concurrent observation and interview on 5/7/2026 at 1 PM with the Certified Dietary Manager, the refrigerator was observed with debris on two shelves and dried brown liquid on the main bottom shelf and side shelf. The CDM stated this was the refrigerator used for residents' food from home and stated that the refrigerator was not clean. During a second concurrent observation and interview on 5/8/2026 at 9:35 AM with RN 1, the same refrigerator was again observed with debris on two shelves and dried brown liquid on the main bottom shelf and side shelf. RN 1 stated the refrigerator needed to be wiped. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, showed that refrigerators and freezers are to be kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary.
Failure to Monitor Antibiotic Use and Culture Results
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one resident with a history of sepsis and UTI. The resident’s record showed intact cognition and a need for maximal assistance with oral hygiene, toileting hygiene, and personal hygiene. The resident had physician orders for multiple antibiotics during the review period, including Macrobid, Levaquin, and Ciprofloxacin for UTI treatment. For the Levaquin order, the McGeer surveillance form was completed for Macrobid but was not completed for Levaquin. The infection prevention nurse stated there was no documented evidence that the surveillance form was completed when the urine culture result was reported, and there was no documented evidence that the resident was symptomatic for UTI or that the ordering physician was communicated with regarding McGeer criteria and the use of Levaquin. The lab report also stated that for long-term care patients, most positive urine cultures represent asymptomatic bacteriuria or contamination and that antibiotic therapy is not recommended without signs and symptoms localizing to the urinary tract. For the Ciprofloxacin order, the resident’s urine culture showed two different bacteria and both were resistant to Ciprofloxacin, yet Ciprofloxacin was administered for the full ordered course. The infection prevention nurse stated there was no documented evidence that the ordering physician was notified of the culture results showing resistance, and the DON stated that giving an antibiotic to which the resident was resistant could result in the antibiotic not being effective, the UTI going unresolved, or recurrent UTIs. The facility’s antibiotic stewardship policy stated that lab results and the current clinical situation should be communicated to the prescriber as soon as available to determine whether antibiotic therapy should be started, continued, modified, or discontinued.
Failure to Send Discharge Notice to Ombudsman
Penalty
Summary
The facility failed to provide discharge notification documentation for Resident 49, specifically the Notice of Proposed Transfer and Discharge, to the State Long-Term Care Ombudsman after the resident was discharged. Resident 49 had been admitted and readmitted to the facility, with diagnoses including COPD and schizoaffective disorder. The resident's H&P dated 1/23/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 2/18/2026 showed moderately impaired cognitive skills for daily decision making, with assistance needed for several activities of daily living. The Notice of Proposed Transfer and Discharge dated 2/18/2026 indicated Resident 49 was discharged on 2/18/2026. During interview, the Social Services Director stated it was the facility's practice to send discharge notifications to the Ombudsman by fax within 30 days of discharge, but Resident 49's discharge notification was not sent. The facility's policy stated residents and/or representatives are to be notified in writing at least 30 days prior to transfer or discharge, and that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.
MDS Did Not Reflect Resident’s Depression Diagnosis
Penalty
Summary
Ensure each resident receives an accurate assessment was not met for one resident whose diagnosis of depression was not accurately reflected in the Minimum Data Set (MDS) dated 4/14/2026. The resident’s admission record showed diagnoses including depression, anxiety, and dementia. The MDS indicated impaired cognition and substantial/maximal assistance for toileting and bathing, but it did not identify depression as a diagnosis. The resident’s Order Summary Report showed an active physician order for Mirtazapine 7.5 mg by mouth at bedtime for depression manifested by poor oral intake of less than 50% of meals, with a start date of 3/12/2026. During interview, the MDS nurse stated there was a discrepancy on the resident’s MDS and that the resident should have been marked as having depression because the resident was actively taking medication for depression at the time. The nurse also stated accurate MDS information was important so it could be reported to the resident’s insurance and reflect the resident’s current treatments. The facility policy stated a resident’s health record should be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident.
Improperly Prepared Liquidized Diet
Penalty
Summary
The facility failed to ensure that Resident 3 received a liquified diet as ordered by the physician. Resident 3 was admitted with diagnoses including dementia and dysphagia, and the MDS indicated severe cognitive deficit and dependence with activities of daily living, including eating. The order summary showed a physician order for a regular diet with liquidized texture and liquidized pureed items for all meals for ease of swallow. During lunch observation, CNA 1 assisted Resident 3 with eating while multiple food items were present on the tray, including a bowl of yellow mashed food and cups containing brown, light brown, and dark yellow liquified foods. The DON observed and tested the foods using the spoon tilt test, and the mashed food did not fall from the spoon, while the liquid food did. The DON stated ordered food needed to be in the form it was ordered to prevent choking. The RRD stated a syringe was used to test a liquidized diet, and staff later stated the bowl of mashed food on the tray was a mistake. The facility's lunch menu included pork roast, rice pilaf, mixed vegetables, and lemon bar, and the facility policy stated modified diets and thickened liquids would be prepared and served in accordance with the IDDSI Framework.
Staff Lack Knowledge of Abuse Reporting Roles and Requirements
Penalty
Summary
The facility failed to ensure that staff understood and followed its abuse reporting policies and procedures. During interviews, three of six sampled staff members (two CNAs and one LVN) were unable to identify the facility’s Abuse Coordinator and did not know the external agencies to which allegations of resident abuse must be reported. Specifically, these staff members did not know that allegations of abuse must be reported to the California Department of Public Health, the Ombudsman, adult protective services, and local law enforcement within two hours when abuse is suspected. The Director of Staff Development stated that the Administrator is the Abuse Coordinator and that all staff are expected to know this and to understand the reporting requirements. The record review included an admission record and history and physical for a resident admitted with schizophrenia, impulse disorder, and hypertension, with documentation that the resident lacked capacity to understand and make decisions due to schizophrenia. The facility’s written policy, “Abuse Prevention and Prohibition Program,” revised 11/28/2022, states that the Administrator or designee serves as Abuse Coordinator and is responsible for reporting known or suspected abuse to proper authorities, and that staff must report suspected abuse to the Administrator or designee. The policy further specifies that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the state survey agency, adult protective services, law enforcement, and the Ombudsman. Despite these written requirements, interviewed staff demonstrated a lack of knowledge of both the designated Abuse Coordinator and the mandated external reporting entities and timelines.
Failure to Timely Report Allegation of Abuse to Required Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident 1 to the California Department of Public Health, the Ombudsman, and local law enforcement within the two-hour timeframe required by its Abuse Prevention and Prohibition Program policy. Resident 1, who had been admitted with schizophrenia, impulse disorder, and hypertension, and was documented in a History and Physical as lacking capacity to understand and make decisions due to schizophrenia, allegedly yelled "rape, rape" when CNA 2 entered the room around 1 PM on 4/4/2026. CNA 2 did not report this allegation until approximately 2:45 PM, when CNA 2 informed LVN 2 that Resident 1 had alleged CNA 2 raped and touched the resident. LVN 2 stated that CNA 2 reported the allegation at 3 PM and acknowledged not reporting the allegation to the Administrator, instead waiting until 5 PM to inform the DON, and stated that the allegation should have been reported right away. Review of Resident 1's Change of Condition/Interact Assessment Form (SBAR) dated 4/4/2026 showed that the resident made an allegation of physical and sexual abuse by unidentified staff, and that the RN supervisor reported the allegation to local law enforcement at 8:30 PM. The SBAR further indicated the Administrator reported the allegation to the Ombudsman at 8:24 PM and to the Department at 8:25 PM. The DON confirmed these reporting times were greater than two hours from when the allegation was made and acknowledged that the allegation was not reported to the Department, the Ombudsman, and local law enforcement in accordance with the facility's Abuse Prevention and Prohibition Program policy, which requires allegations of abuse to be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency, adult protective services, law enforcement, and the Ombudsman.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition policy after a fall experienced by Resident 1. Resident 1 had multiple diagnoses including abnormalities of gait and mobility, unspecified dementia, and a history of falling, and had been assessed as a fall risk on a Fall Risk Evaluation that directed staff to alert the physician if a fall occurred. An MDS assessment indicated Resident 1 had moderately impaired cognition and was dependent for ADLs, requiring supervision or touching assistance. Despite these identified risks, when Resident 1 fell, the required assessments and notifications were not completed. On 1/9/2026 at approximately 3 AM, LVN 2 heard an alarm from the back hallway, entered Resident 1’s room, and found Resident 1 sitting on the floor in front of the roommate’s bed. Resident 1 stated, “I do not know, I just fell.” LVN 2 noted an abrasion on Resident 1’s mid-back on the right side and notified Resident 1’s primary nurse, LVN 3, who stated LVN 2 would resume follow-up. There was no documented evidence that a post-fall assessment was completed, that the physician was notified, or that a Change of Condition (COC) form was initiated for this event, despite the facility’s policy requiring prompt handling, documentation, and physician notification for changes such as bruises, lacerations, and other injuries. During subsequent interviews and record reviews, the DON confirmed that the progress note from 1/9/2026 indicated a fall and that LVN 2, as charge nurse, was responsible for completing the COC, which was not found in the record. The DON also confirmed there was no documentation that the physician was notified or that an assessment was completed after the fall. LVN 1 and LVN 3 both acknowledged that a fall constitutes a change of condition and that it is important to assess the resident and notify the physician and family, yet LVN 3 stated they did not assess Resident 1 after the fall and relied on LVN 2 to “take care of the incident.” The facility’s Change of Condition policy required proper assessment, prompt handling, licensed nurse documentation, completion of a COC, and prompt physician notification with daily assessments, which were not carried out in this case.
Failure to Obtain Informed Consent for Alarms and Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of bed and wheelchair alarms, as well as for the administration of two anti-depressant medications, Lexapro and Remeron, for one resident. The resident, who had diagnoses including Alzheimer's disease, dementia, and muscle weakness, was assessed as having severely impaired cognition. Despite facility policy requiring informed consent prior to the use of safety devices and psychotherapeutic medications, there was no documentation of consent being obtained from the resident or their responsible party before implementing these interventions. Observations confirmed that the resident was using bed and wheelchair pad alarms, and physician orders for both the alarms and the medications specified that informed consent should be obtained. Interviews with facility staff, including a CNA, LVN, and RN Supervisor, confirmed that the required consents were not present in the resident's records. Facility policies reviewed also indicated that informed consent must be obtained and documented prior to the use of such interventions, but this process was not followed for the resident in question.
Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were obtained and maintained in the medical records for three of five sampled residents. For each of these residents, documentation indicated that an AD had been executed, as shown by their Advance Healthcare Directive Acknowledgement (AHDA) forms. However, during record review, the Social Services Assistant (SSA) was unable to locate copies of the actual ADs in the residents' medical records, despite facility policy requiring that such documents be readily retrievable. Resident 14 and Resident 145 both had severe cognitive impairment and lacked capacity to make decisions, as documented in their History and Physicals and Minimum Data Sets. Their care plans referenced respecting the wishes specified in their ADs, but the actual AD documents were not present in their records. Resident 38, who had intact cognition and capacity, also had an AHDA indicating an executed AD, but the AD itself was missing from the file. In all three cases, the POLST forms on file noted that the POLST was not a substitute for an AD and should complement, not replace, the AD. The SSA confirmed responsibility for obtaining and filing ADs upon admission and acknowledged that the facility had not followed through in securing and maintaining these documents in the residents' records. Facility policy required that executed ADs be obtained and kept in a specific section of the medical record, but this was not done for the three residents in question.
Failure to Obtain and Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to obtain and document weekly weights for three residents as required by physician orders and the facility's own policy. For one resident with heart failure and dementia, the weight was not taken upon readmission or on the date specified by the physician order. The Restorative Nurse Assistant (RNA) reported weighing the resident upon return but did not have access to the electronic documentation system and provided the weight to the Infection Preventionist (IP) on paper. The IP did not enter the weight into the system and had no documentation to confirm the weight was taken. Another resident with dysphagia, hypertension, and acute kidney failure experienced significant weight loss, and a physician order was in place for weekly weights. However, the medical record showed no weights were recorded on two consecutive weeks as required. Both the Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) confirmed that weights were missing and acknowledged the importance of monitoring weight for residents experiencing weight loss. A third resident with multiple diagnoses, including dementia and anxiety disorder, also had a physician order for weekly weights due to recent weight loss. The care plan and nutritional assessment indicated the need for close monitoring, but the weekly weight for one of the required weeks was not documented. The RNA, responsible for weighing residents, stated that weights were sometimes taken on different days depending on workload and that the Director of Nursing (DON) was responsible for entering weights into the electronic record. The facility's policy required weekly weights for all residents for four weeks after admission or readmission, but this was not consistently followed or documented.
Failure to Label and Date Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage practices in the kitchen's walk-in refrigerator. Specifically, a transparent container with sliced cheese was not labeled with an open date, a halfway-filled jar of hamburger pickles was not labeled with an open date, and two unopened plastics of whipping cream were not labeled with a received date. These observations were made during a walkthrough with the Certified Dietary Manager, who confirmed that food items should be labeled with open and receive dates to monitor quality and freshness. Further interview with the Registered Dietitian confirmed that all items in the refrigerator should be labeled with open and receive dates to track when food items arrived, determine when to discard them, and ensure the highest quality of food served to residents. Review of the facility's policy and procedure on Refrigerator/Freezer Storage indicated that leftover food or unused portions of packaged foods should be covered, dated, and labeled, and that all items should have appropriate delivery, open, and thaw dates. The facility's failure to follow these procedures led to the cited deficiency.
Arbitration Agreements Lacked Required Communication Provision
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included a provision allowing residents or their representatives to communicate with federal, state, or local officials. This deficiency was identified during interviews and record reviews for two residents. In both cases, the Admission Coordinator confirmed that the arbitration agreements signed by the residents' responsible parties did not contain a selection or statement affirming the right to communicate with authorities such as surveyors or the Ombudsman. One resident had a history of schizophrenia, bipolar disorder, and anxiety, while the other had chronic obstructive pulmonary disease, major depressive disorder, and psychosis, with documented intact cognition and partial assistance needs for daily activities. The omission in the arbitration agreements was acknowledged by the Admission Coordinator, who stated the importance of allowing such communication to honor residents' rights.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for six sampled residents, as evidenced by multiple observations and staff interviews. Personal toiletries and resident care items belonging to four residents were found unlabeled and improperly stored in a shared restroom, with items such as an opened cleanser, uncapped shaving cream, and a wash basin left accessible. Staff confirmed these items should have been labeled and secured in residents' closets to prevent cross-contamination, especially since some residents were ambulatory and could access items not belonging to them. Additionally, a resident with severe cognitive impairment was observed independently pouring water from a communal pitcher on a medication cart in the hallway, with no staff intervention. Staff interviews confirmed that residents should not be allowed to serve themselves from communal drink pitchers due to infection control concerns, as residents could contaminate the pitchers with dirty hands or by returning unwanted liquid. Facility policy also required measures to prevent the transmission of communicable diseases, which were not followed in this instance. Further deficiencies included a heavy accumulation of lint in two out of three dryer lint traps in the shared laundry room, contrary to the facility's schedule requiring frequent cleaning. Staff acknowledged the risk and admitted to not cleaning the lint traps as often as required. In another instance, a resident's bed sheets and room wall were observed with brown streaks suspected to be stool, and staff confirmed the resident had a history of handling feces and was unable to clean their own hands. Lastly, a used cup with leftover liquid was found on a hallway handrail, and staff stated that such items should not be left unattended as they could be used by other residents, posing an infection risk.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple mental health diagnoses was not provided adequate privacy and dignity during personal care. The resident was observed sitting in a shower chair at the bedside with the right flank and thigh exposed. The privacy curtains were only partially drawn, and the room door was propped open while a CNA was outside the room donning PPE. During this time, several male residents were walking in the hallway, making the resident's exposure visible to others. The resident's care plan specifically included interventions to maintain privacy and respect the resident's rights. Facility policy and procedures also required staff to close the room entrance door and ensure bodily privacy during personal care. Both the CNA and the RN Supervisor acknowledged that the resident's body was exposed and should have been covered for dignity and privacy. The failure to follow these protocols resulted in the resident being exposed in a manner inconsistent with facility policy and the resident's care plan.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed during a survey. The resident, who had a history of unspecified dementia, psychotic and mood disturbances, and anxiety, was assessed as having severely impaired cognition and required varying levels of assistance with activities of daily living. During the observation, the resident was seated in a wheelchair in the middle of the room, facing away from the bed, while the call light was secured around the right-side grab bar of the bed, making it inaccessible to the resident. A Certified Nursing Assistant confirmed that the call light was not within the resident's reach and acknowledged that it should have been accessible in case the resident needed help. The Registered Nurse Supervisor also stated that call lights must be within reach for all residents, including those who are confused, to allow them to call for assistance. The facility's policy and procedure on call lights required staff to ensure that call lights are within reach when residents are in their rooms or on the toilet.
Failure to Update Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a required assessment following a significant change in condition for a resident who was readmitted with multiple diagnoses, including dementia and major depressive disorder. Upon review, it was found that the resident's Minimum Data Set (MDS) did not reflect a new diagnosis of bipolar disorder, despite the presence of a physician's order for Depakote to treat this condition. The MDS Coordinator confirmed that the resident's hospital records, which should have been reviewed upon readmission, indicated treatment for bipolar disorder, and that this diagnosis should have been documented in both the Admission Record and the MDS. Further review of the resident's active orders and physician progress notes confirmed ongoing treatment for bipolar disorder, yet the diagnosis was not included in the facility's official records. The facility's policy requires that health records be current and detailed, consistent with good medical and professional practice. The omission of the bipolar disorder diagnosis in the resident's records and assessment tools represented a failure to update documentation after a significant change in the resident's condition.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a required Level II Pre-Admission Screening and Resident Review (PASARR) evaluation for a resident who had a positive Level I PASARR screening for serious mental illness (SMI). The resident was initially admitted with diagnoses including traumatic subdural hemorrhage, seizures, and hypertension. The Level I PASARR screening, conducted after admission, indicated the need for a Level II evaluation, but there was no documentation that this evaluation was ever completed. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that there were no records of a Level II PASARR evaluation for the resident, despite facility policy requiring such an evaluation for residents with a positive Level I result. The facility's policy also required staff to review PASARR information regularly, follow up with the appropriate contractors, and maintain documentation, none of which was evidenced in this case.
Failure to Develop Care Plan for New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to develop a care plan addressing bipolar disorder for a resident who was readmitted following a hospital stay. The resident's admission record indicated multiple diagnoses, including dementia and major depressive disorder, and hospital records obtained during the recent hospitalization included a new diagnosis of bipolar disorder. However, the Minimum Data Set (MDS) completed after readmission did not list bipolar disorder as an active diagnosis, and no care plan was created to address this new condition. Interviews with the Minimum Data Set Coordinator (MDSC) revealed that the resident's medical record should have reflected the new bipolar disorder diagnosis and that a care plan should have been developed upon admission to ensure staff awareness and appropriate interventions. The facility's policy required the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition or upon readmission from a hospital stay, but this was not done for the resident in question.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 20 out of 23 resident rooms met the minimum required space of 80 square feet per resident in rooms with more than one occupant. Documentation from the Resident Listing Report and Client Accommodation Analysis showed that multiple rooms, each housing two residents, measured only 140 square feet, resulting in less than the required space per resident. Additionally, one room with four residents measured 308 square feet, also falling short of the standard. These findings were based on a review of facility records and room measurements. A waiver request letter from the facility stated that reasonable privacy, closet, and storage space were provided, and that there was sufficient room for nursing care and resident equipment. During an observation and interview, a CNA was able to move freely and provide care in a room with two wheelchairs present, and reported no issues with space when attending to residents. However, the documented room sizes did not meet the regulatory requirements for square footage per resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident at risk for elopement, leading to the resident leaving the facility unnoticed. The resident, who had diagnoses of dementia and major depressive disorder, was identified as having moderately impaired cognition and required supervision for daily activities. Despite these needs, the resident was able to elope from the facility without staff noticing, as staff were occupied with assisting other residents during mealtime. The incident occurred when a CNA and a Dietary Aide entered the hallway from the exit door and failed to ensure the door was closed or locked. The resident was seen on surveillance video holding the door open and subsequently leaving the facility. Interviews with staff revealed that during mealtimes, there was no one monitoring the exit door, as staff were busy feeding residents. This lack of supervision allowed the resident to leave the facility unnoticed. Upon the resident's return, it was noted that the resident had sustained a skin tear on the left arm. The facility's policy and procedure emphasized the importance of continuous supervision and redirection to prevent accidents and elopements, which was not adhered to in this case. Staff interviews confirmed that there was a lapse in monitoring and that the exit door was not properly checked, contributing to the resident's elopement.
Facility Fails to Maintain Acceptable Temperature Range
Penalty
Summary
The facility failed to maintain an acceptable temperature range as per its policy, affecting six resident rooms, one dining room, and one hallway. The air conditioning unit for the middle part of the nursing unit malfunctioned, leading to temperatures ranging from 84.4 to 97 degrees Fahrenheit, which exceeded the facility's acceptable range of 71 to 81 degrees Fahrenheit. The Director of Nursing acknowledged the issue, stating that the air conditioner had been broken since the previous day, and fans were being provided to residents as a temporary measure. The Maintenance Director confirmed the malfunction and stated that the HVAC technician was working on replacing the condenser. The air conditioning unit was reportedly fixed later that day. The facility's policy, titled 'Homelike Environment,' emphasized maintaining comfortable and safe temperatures, which was not adhered to during the malfunction. The Maintenance Supervisor's job description highlighted the responsibility for maintaining the facility in good repair, including mechanical systems, which was not fulfilled in this instance.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 6,390 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mayflower Care Center | 0 mi | ★★★★★ | 3 | 0 |
| The Gardens Of El Monte | 0.9 mi | ★★★★★ | 23 | 0 |
| Fidelity Health Care | 1.1 mi | ★★★★★ | 3 | 0 |
| Temple City Healthcare | 1.3 mi | ★★★★★ | 36 | 0 |
| Community Care Center | 1.6 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.