Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Care Center during CMS and state inspections, most recent first.
Multiple residents with conditions including DM2, dementia, HTN, insomnia, edema, COPD, and mental health disorders did not receive their ordered night medications when staff were unable to access the electronic MAR due to a computer issue and did not obtain backup MARs or notify administrative staff, resulting in missed doses of critical medications such as insulin, Eliquis, metoprolol, Lasix, and others, with no adverse reactions documented in the incident log.
The facility failed to report two separate resident-to-resident physical altercations involving bodily injury to the State Agency. One resident sustained red, spotted bruises to the left arm after being struck with another resident’s wallet chain, and another resident reported being hit on the head by a peer, with a reddened area noted. Both events were documented internally as incidents resulting in serious bodily injury and as changes in condition, but review of the facility’s reportable incident list showed that neither incident was submitted to the State Agency. Interviews with the involved resident and the ADM confirmed the altercation and the failure to file the required reports.
Two residents identified as high risk for falls did not have fall mats present as ordered by their physicians and care plans. Observations and interviews with staff and family confirmed that fall mats were missing while the residents were in bed, despite clear orders and care plan interventions requiring their use.
The facility did not ensure that a licensed pharmacist completed monthly drug regimen reviews for multiple residents and failed to implement pharmacy recommendations that were approved by providers. These lapses included not discontinuing pain medications, not monitoring for medication side effects, and not updating the EMR with new orders as required.
A resident was permitted by provider order to have one beer daily, with the beer to be stored in a locked refrigerator per the care plan. However, the resident kept beer in a cooler in his room and accessed it daily, with staff and family assisting, which did not align with the documented care plan. Both the DON and Administrator confirmed this inconsistency between the care plan and actual practice.
A resident on blood thinners experienced a significant forearm injury that was not promptly communicated to the Providers or DON. The injury was discovered in the morning by an RN and CNA, but the resident was not reassessed throughout the day, leading to increased bleeding and a delayed hospital visit. The NP and DON were not informed until the resident was sent to the ER, highlighting a failure in communication and documentation.
A resident on blood thinners suffered a self-inflicted forearm laceration that was not properly monitored or communicated between shifts, leading to worsening of the wound and hospitalization. The initial dressing was not reassessed throughout the day, and staff interviews revealed a breakdown in communication and adherence to care protocols.
A resident with Alzheimer's and limited mobility did not receive adequate toenail care, as required by their care plan. Despite complaints from the resident's family, the facility staff only trimmed the resident's toenails twice in a month, leading to an ER visit where hospital staff had to address the issue. The DON confirmed that toenail care was not performed as expected.
The facility failed to maintain accurate medical records for three residents, leading to potential miscommunication and inadequate care. One resident's non-weight bearing status was not documented, affecting his referral to a Home Health provider. Another resident's records lacked documentation of a significant change in condition and hospital transfer. A third resident's behavioral issues were not accurately recorded, despite multiple incidents. These deficiencies highlight lapses in record-keeping and communication within the facility.
A facility failed to report and investigate an injury of unknown origin for a resident. The DON spoke with an RN about the incident but did not conduct a complete investigation, believing it unnecessary. A unit investigation was conducted involving multiple residents and an RN, but the specific resident was not included. The ADM also did not complete an investigation, relying on the DON's incomplete unit investigation. Both the DON and ADM acknowledged the oversight.
A facility failed to update a resident's care plan to include the use of an anticoagulant, apixaban, as ordered by the physician. The resident's care plan addressed risks for falls due to confusion and balance issues but omitted the anticoagulant information. The DON confirmed that the staff should have updated the care plan but did not.
The facility failed to properly sanitize glucometers between uses during FSBS tests, leading to potential cross-contamination. Staff used alcohol wipes instead of the required antiviral wipes, and glucometers were inappropriately stored in clothing pockets. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as staff were unaware of EBP requirements and lacked necessary signage and PPE. The facility also failed to update infection control policies annually and did not have adequate water safety management controls.
The facility did not have a qualified Infection Preventionist (IP) with the necessary specialized training in infection prevention and control. The Administrator identified a staff member as the IP, but no certificate of completion was provided. The staff member confirmed they had only completed state training on COVID-19 and was in the process of obtaining further certification. The previous IP left in March, and the current Director of Nursing, who had been in the role for three weeks, had not yet received the required training.
The facility failed to maintain clean or dust-free filters on oxygen concentrators for five residents, increasing the risk of infection. Observations revealed dirty filters filled with lint and debris, and in some cases, missing filters. Staff interviews indicated confusion about who was responsible for cleaning the filters, with the Central Supply staff admitting to possibly missing checks. The DON and Administrator were unaware of the issue until it was pointed out, highlighting a breakdown in procedures for maintaining respiratory care equipment.
A facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included improper application of Lidoderm patches, failure to administer levothyroxine and lisinopril as ordered, and incorrect dosage of Vitamin B-12. Staff did not document refusals or ensure medications were given per physician orders.
A facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN), leaving them uninformed about potential non-coverage by Medicare and the associated costs. The Social Services Director and Business Office Manager did not issue the SNFABN form, and the resident was not given written notice of their financial responsibilities despite having remaining benefit days.
A resident admitted to hospice services with a terminal diagnosis did not have a Significant Change MDS completed within the required 14-day period. Despite the requirement in the RAI Manual, the facility failed to complete this assessment, as confirmed by interviews with MDS coordinators and the DON. This oversight could potentially place the resident at risk for unmet care needs.
A facility failed to complete a quarterly MDS assessment for a resident with multiple health conditions, missing the deadline by 25 days. The oversight was confirmed by MDS1, who acknowledged the error despite having a tracking system in place. The resident's previous assessments were completed, but the third quarterly assessment was not conducted as required by federal regulations.
The facility failed to accurately code the MDS for two residents receiving hospice services and one resident receiving insulin. One resident was incorrectly coded as not having a terminal condition or receiving hospice, despite being on hospice since June 2023. Another resident's MDS was inaccurately coded as not receiving hospice services, although they had been on hospice since March 2024. Additionally, a resident was incorrectly coded for insulin injections instead of semaglutide (Ozempic) injections. The MDS coordinator admitted to errors due to oversight and reliance on physician orders.
The facility failed to create comprehensive care plans for three residents, including one with end-stage renal disease requiring dialysis, another with acute respiratory failure needing supplemental oxygen, and a third with PTSD. Despite assessments indicating the need for specific care plans, these were not developed, as confirmed by staff interviews.
A resident was prescribed a 5% Lidoderm patch for shoulder pain, but an LPN administered a 4% patch due to insurance limitations. The MAR lacked dosage details, and the NP did not specify a dosage, assuming the 4% patch was standard. The DON confirmed that all medication orders should include dosage, revealing a policy-practice gap.
A resident experienced a gradual, unintentional weight loss over several months without adequate assessment or intervention by the facility. Despite being at risk for weight loss and dehydration, no significant dietary recommendations or weight loss plan were documented. The RD did not intervene, citing a lack of significant weight loss, and the DM failed to document communication with the RD. The facility's policy required monitoring and intervention, which was not followed, leading to a deficiency in care.
A resident with essential hypertension received lisinopril without consistent blood pressure monitoring, contrary to physician orders. The facility's records showed that blood pressure was not documented on many days, yet lisinopril was administered daily, even when the systolic blood pressure was below the prescribed threshold. The DON confirmed the expectation for blood pressure monitoring and acknowledged the oversight.
A resident admitted for rehabilitation services did not receive the ordered physical and occupational therapy evaluations due to a misunderstanding about her status as a long-term care resident. Despite the resident's care plan indicating a need for therapy to address fall risks, no evaluations were documented. The Director of Therapy confirmed the oversight, and the Administrator expected evaluations to be completed as ordered.
A facility failed to update the care plan for a resident with multiple diagnoses, including vascular dementia and ataxia, who sustained bruises on both hands. The bruises were caused by the resident's improper use of a wheelchair, which was not addressed in the care plan. Despite the resident's need for total assistance with wheelchair use, the care plan lacked this information, indicating a failure to provide appropriate care.
Missed Night Medications Due to MAR Access Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when night medications were not administered on 03/30/26. Record review showed that one resident with diagnoses including type 2 DM, hyperlipidemia, major depressive disorder, anxiety, GERD, and COPD did not receive multiple ordered medications that night, including docusate sodium, fluticasone-salmeterol, glipizide, insulin, Nubeqa, and tolterodine tartrate ER. Another resident with dementia, anxiety, and essential HTN did not receive donepezil HCl, lorazepam, trazodone HCl, levetiracetam, or metoprolol tartrate as ordered on the same night. A third resident with essential HTN, insomnia, and generalized edema did not receive melatonin, senna, Eliquis, gabapentin, or Lasix on the night in question. Review of the facility’s incident log showed no documented adverse reactions related to the missed medications. During an interview, the Administrator stated that a computer issue prevented staff from accessing the MAR, resulting in night medications not being given, and acknowledged that staff did not contact administrative staff or access backup MARs when the problem occurred.
Failure to Report Resident-to-Resident Abuse Incidents to State Agency
Penalty
Summary
The facility failed to report to the State Agency two incidents involving allegations of resident-to-resident physical abuse that resulted in bodily injury. Facility records showed that on 04/01/26, one resident (R #2) sustained red, spotted bruises to the left arm after being hit with another resident’s wallet chain, documented as an incident resulting in serious bodily injury (bruise) and as a change of condition. A separate incident report for the same date documented that another resident (R #3) reported being hit on the head by another resident, with a slightly reddened area noted on the right side of the head and classified as an incident resulting in serious bodily injury (bruise). Review of the facility’s reportable incident list revealed that neither of these incidents was submitted to the State Agency. During interviews, R #2 confirmed he had been in a physical altercation and was hit with a chain, and the Administrator confirmed that the required reports for both residents had not been filed. These findings were based on review of the facility’s Incident by Incident Type report, change of condition assessment, progress notes, and reportable incident list, as well as interviews with the residents and the Administrator.
Failure to Provide Fall Mats as Ordered for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall mats were present for two residents identified as high risk for falls, as ordered by their physicians and outlined in their care plans. One resident, who had a history of confusion, gait and balance problems, and paralysis, was care planned to have a fall mat present when in bed. Multiple observations revealed that the fall mat was not present while the resident was in bed, and this was confirmed by the resident's daughter, a CNA, the Director of Rehab, and the DON, all of whom acknowledged that a fall mat should have been in place. Similarly, another resident with a physician order for a fall mat to be present when in bed was observed lying in bed without the required fall mat. This absence was confirmed by the Scheduler and the DON, both of whom stated that a fall mat should have been present according to the physician's order. These findings were based on direct observations, interviews with staff and family, and review of care plans and physician orders.
Failure to Complete Monthly Pharmacy Reviews and Implement Approved Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed the required monthly drug regimen reviews for several residents over multiple months. Specifically, pharmacy reviews were not completed for three residents from August 2024 through October 2025. Additionally, pharmacy recommendations that were approved by providers were not implemented for two residents. These recommendations included discontinuing certain pain medications and monitoring for dermatological side effects related to specific prescriptions. In another instance, recommendations to monitor for involuntary movements were approved but not carried out as ordered. Record reviews confirmed that the Medication Regimen Review (MRR) documentation was either missing or not acted upon, and interviews with the DON verified that these omissions occurred and should have been addressed. The failures included not adding new orders to the electronic medical record (EMR) after provider approval and not following through with monitoring or discontinuation of medications as recommended by the pharmacist and approved by the provider.
Failure to Implement Accurate Care Plan for Resident's Alcohol Storage
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered comprehensive care plan for a resident regarding the storage and access to beer, as ordered by the provider. Observation and interviews revealed that the resident kept a cooler with beer in his room and accessed it daily, consistent with his statement and the provider's order allowing one beer per day. However, the care plan documented that the beer should be stored in a locked refrigerator in the restorative area, not in the resident's room. Both the DON and Administrator confirmed the discrepancy between the care plan and the actual practice, with staff and family facilitating the resident's access to beer from the cooler in his room, contrary to the care plan instructions.
Failure to Notify Providers and DON of Resident's Injury
Penalty
Summary
The facility failed to notify the Providers and the Director of Nursing (DON) of a change in condition for a resident who experienced a large left forearm injury. The resident, who was on a blood thinner medication, was found with a significant skin tear by a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) in the early morning. The RN dressed the wound and reported the injury to the oncoming RN but did not notify the DON or the Provider. Throughout the day, the resident's condition was not reassessed, and no further documentation was made until the evening when the resident was sent to the emergency room due to increased bleeding. Interviews with the Nurse Practitioner (NP) and the DON revealed that they were not informed of the injury until the resident was sent to the hospital. The NP stated that she should have been notified immediately to provide additional treatment and potentially prevent the worsening of the injury. The DON confirmed that it was her expectation for the nursing staff to notify her and the facility providers immediately when a resident experiences a significant injury. The lack of communication and documentation likely contributed to the delay in appropriate medical intervention for the resident.
Failure to Monitor and Communicate Resident's Wound Care
Penalty
Summary
The facility failed to provide proper wound care and monitoring for a resident's left forearm laceration, which was discovered by a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) during the morning shift. The resident, who was on a blood thinner medication, was found with a large gash on the left forearm that appeared to be self-inflicted. The RN dressed the wound but did not clean it, and the severity of the injury was not effectively communicated to the oncoming day shift nurse or other relevant staff members. Throughout the day, the resident's wound was not reassessed, and no further documentation was made regarding the condition of the injury. The lack of monitoring and communication resulted in the wound bleeding profusely, necessitating the resident's transfer to the emergency room later that evening. Interviews with staff revealed a breakdown in communication, with the day shift nurse claiming she was not informed of the injury, and the wound care nurse not being made aware of the situation until after the resident returned from the hospital. The Director of Nursing (DON) and other staff members confirmed that the facility's protocol requires nurses to assess each resident every shift, which was not adhered to in this case. The failure to reassess and properly manage the resident's wound throughout the day led to the worsening of the injury, highlighting significant lapses in communication and adherence to care protocols within the facility.
Failure to Provide Adequate Toenail Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident, specifically in the area of toenail care. The resident, who had Alzheimer's disease, fatigue, impaired balance, and limited mobility, required staff assistance for ADL care. Despite the care plan indicating the need for such assistance, the facility's records showed that the resident's toenails were only trimmed and cleaned twice over a month-long period. This lack of regular care led to the resident being admitted to the emergency room, where hospital staff had to trim the resident's long toenails to improve mobility. Interviews with the resident's Power of Attorney and facility staff revealed that complaints about the resident's toenail care were made multiple times. A Certified Nursing Assistant (CNA) acknowledged receiving complaints from the resident's family and the facility's social worker. The CNA admitted that the resident's toenails appeared neglected despite the complaints. The Director of Nursing confirmed that the facility's expectation was for CNAs to check and care for residents' toenails during each shower, which was not done in this case.
Incomplete and Inaccurate Medical Records for Three Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential miscommunication and inadequate care. For the first resident, the medical records did not reflect his non-weight bearing status, which was crucial information for his referral to a Home Health provider. The resident was discharged from the facility without this critical information being documented, resulting in his inappropriate acceptance into a program that required weight-bearing capability. The Social Services Coordinator confirmed that the referral documentation lacked this essential detail. The second resident's medical records were incomplete, missing documentation of a significant change in her condition. The resident experienced difficulty breathing, was transferred to a hospital, tested positive for COVID-19, and later returned to the facility. However, her medical records did not include any notes about her breathing difficulties, hospital transfer, or return, which the Director of Nursing acknowledged should have been documented. For the third resident, the facility's records failed to accurately reflect his behavioral issues and incidents. Despite multiple reports of the resident refusing care, threatening staff, and exhibiting aggressive behavior, the daily care notes consistently described him as having a pleasant mood with no behaviors witnessed. The Administrator confirmed that these incidents were not documented in the resident's medical records, indicating a significant lapse in accurate record-keeping.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an investigation regarding an injury of unknown origin for a resident. The Director of Nursing (DON) spoke with a Registered Nurse (RN) about the incident but did not conduct a complete investigation, believing it unnecessary after the conversation. The DON conducted a unit investigation involving multiple residents and RN #1, who was involved in the incident, but did not specifically include the resident in question. The Administrator (ADM) also did not complete an investigation for the resident's injury, relying on the DON's unit investigation, which did not specifically address the resident's case. Both the DON and ADM acknowledged that the resident should have been included in the investigation but was not.
Failure to Update Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to update the care plan for a resident to include the use of an anticoagulant medication, apixaban, which was ordered by the physician. The resident was admitted and later discharged from the facility, and during their stay, a physician's order dated 07/09/24 indicated the need for apixaban, 5 mg twice a day. However, the care plan, which was supposed to address the resident's risk for falls due to confusion, balance, vision, and hearing problems, did not include any information about the anticoagulant use. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the staff should have updated the care plan to reflect the anticoagulant use but failed to do so.
Infection Control Deficiencies in Glucometer Sanitization and EBP Implementation
Penalty
Summary
The facility failed to properly sanitize glucometers between uses during fingerstick blood sugar tests (FSBS) for three residents, leading to potential cross-contamination. Observations revealed that a registered nurse (RN) and a licensed practical nurse (LPN) did not use the appropriate disinfecting wipes as per the facility's policy and instead used alcohol wipes, which are not sufficient for disinfection. The RN and LPN admitted to not following the correct procedure, and the Director of Nursing (DON) confirmed that the facility's policy required the use of antiviral wipes. The DON also noted that carrying the glucometer in a clothing pocket was inappropriate and posed an infection control issue. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters, suprapubic catheters, and feeding tubes. Observations and interviews with staff and residents indicated a lack of signage and personal protective equipment (PPE) in place for these residents. Staff members, including LPNs and certified nurse aides (CNAs), were unaware of the EBP requirements, and the facility's administrator did not recall receiving the relevant memo from the Centers for Medicare and Medicaid Services (CMS) regarding EBP implementation. Additionally, the facility did not update its infection control policies and procedures on an annual basis and lacked control measures to monitor their water safety management program. The maintenance director admitted to not having test results for Legionella and was under the impression that testing was conducted by the city. The administrator confirmed that the facility had not experienced any outbreaks but acknowledged that testing was not being conducted as part of their preventative maintenance program.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) with specialized training in infection prevention and control, as required by their policy. The policy, revised in September 2022, mandates that the IP must have evidence of training through a certificate of completion or equivalent documentation. During an entrance conference interview, the Administrator identified the Minimum Data Set (MDS) 1 as the IP since February 2024. However, upon review, no certificate was presented for the IP. In an interview, MDS1 confirmed being the IP as of the previous day and mentioned having taken state training on COVID-19 but had not completed other necessary training. The Administrator further explained that the former Director of Nursing (DON), who was the IP, left in March 2024, and the current DON, who had been in the position for three weeks, was yet to receive the required training. MDS1 was in the process of obtaining certification.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure that oxygen concentrators had clean or dust-free filters for five residents, which could increase the risk of infection and unnecessary respiratory treatment. The facility's policy required that oxygen concentrator filters be washed every seven days, but observations revealed that the filters were dirty and filled with lint and debris. For Resident 7, the oxygen concentrator filter was observed to have a significant buildup of white lint and debris over several days, and staff interviews indicated a lack of clarity about who was responsible for cleaning the filters. Resident 19's oxygen concentrator was also observed to have a dust-filled filter on multiple occasions. Similarly, Resident 16's oxygen concentrator had a dust-filled filter, and the Assistant Director of Nursing acknowledged the need for cleaning. Resident 47's oxygen concentrator was missing a filter entirely, and staff interviews revealed that nurses were expected to check the filters when changing tubing. Resident 132's concentrator also lacked a filter, and the Director of Nursing stated that the equipment should include inlet filters to prevent dust and other particles from entering. Interviews with staff, including Licensed Practical Nurses, Central Supply staff, and the Director of Nursing, highlighted a lack of communication and responsibility regarding the maintenance of oxygen concentrator filters. The Central Supply staff claimed to perform routine checks but admitted to possibly missing the filter on Resident 7's concentrator. The Director of Nursing and Administrator were unaware of the issue until it was brought to their attention, indicating a breakdown in the facility's procedures for ensuring proper respiratory care equipment maintenance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20% error rate during the survey. This was observed in the cases of three residents. For one resident, Lidoderm patches were not applied or removed as per the physician's orders. The resident was supposed to have patches applied to both shoulders in the morning and removed at bedtime, but this was not consistently done. The nurse involved stated that the resident sometimes refused the patches, but there was no documentation of such refusals or the removal of the patches at night. Another resident did not receive their prescribed medications, levothyroxine and lisinopril, as ordered. The LPN preparing the medications did not attempt to administer levothyroxine, assuming the resident would refuse it, and failed to administer lisinopril despite the resident's blood pressure being within the required range. The LPN admitted to not asking the resident if they wanted to take the levothyroxine and realized the error only after administering the other medications. A third resident received an incorrect dosage of Vitamin B-12. The resident was prescribed 500 mcg, but the LPN administered 1000 mcg because the facility only had 1000 mcg tablets available and staff were not allowed to split tablets. The LPN acknowledged the error and suggested ordering the correct dosage from the pharmacy. The facility's administration and DON stated that their expectation was for medications to be administered as ordered and for staff to inform residents of medication risks and benefits.
Failure to Provide SNFABN Documentation
Penalty
Summary
The facility failed to provide written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) for a resident reviewed for beneficiary notices. The resident, identified as R27, was not informed in writing about the potential non-coverage of services by Medicare, the reasons for this, or the estimated daily costs they would incur if they chose to continue receiving skilled services. This lack of documentation meant that the resident was unable to make an informed decision regarding their care and financial responsibilities. The facility's policy required that residents be informed verbally and in writing about Medicare and Medicaid benefits, including any changes to covered services. However, interviews with the Social Services Director (SSD) and the Business Office Manager (BOM) revealed that the SNFABN form was not issued to R27, and the BOM was unfamiliar with the form. Despite the resident having remaining benefit days, the facility did not provide the necessary documentation to R27, who chose to remain in the facility. The SSD acknowledged discussing costs verbally but did not provide the required written notice.
Failure to Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) within 14 days for a resident who was admitted to hospice services. The resident, who had a terminal diagnosis of sequelae of cerebrovascular disease, was admitted to hospice services on March 18, 2024. Despite the requirement outlined in the MDS-3.0 Resident Assessment Instrument (RAI) Manual, which mandates the completion of a Significant Change in Status Assessment (SCSA) whenever a resident elects the hospice benefit, the facility did not complete this assessment within the required timeframe. Interviews with facility staff, including the MDS coordinators and the Director of Nursing (DON), confirmed that the significant change MDS was not completed as required. The MDS coordinators acknowledged the oversight, stating that the assessment should have been completed within the 14-day period following the resident's admission to hospice services. The DON and the Administrator also expressed that their expectation was for the MDS to be completed accurately and timely, in accordance with the RAI manual. The failure to complete the significant change MDS could potentially place the resident at risk for unmet care needs.
Missed Quarterly MDS Assessment for a Resident
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for a resident, identified as R43, who was reviewed for completion of MDS assessments. The facility was overdue by 25 days in completing this assessment. According to the facility's policy, quarterly assessments are federally mandated under the Omnibus Budget Reconciliation Act (OBRA) and are required to be performed for all residents in Medicare and/or Medicaid certified nursing homes. These assessments are crucial for tracking the resident's status between comprehensive assessments and ensuring the monitoring of critical indicators of significant changes in resident status. R43 was admitted to the facility with multiple diagnoses, including type two diabetes mellitus, hypothyroidism, peripheral vascular disease, acute hematogenous osteomyelitis, end-stage renal disease, and a complete traumatic amputation of the right midfoot. The resident's admission MDS assessment was completed, followed by quarterly assessments on two occasions. However, the third quarterly MDS assessment, due by mid-June, was not completed. During an interview, MDS1 confirmed the oversight, stating that the assessment was missed despite having a calendar to track due dates and a system in place to ensure care plans were updated. MDS1 acknowledged the error, indicating that the resident's quarterly MDS assessment had been inadvertently skipped.
Inaccurate MDS Coding for Hospice and Insulin Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents receiving hospice services and one resident receiving insulin, which could potentially place the residents at risk for care needs not being addressed. For Resident 7, the MDS was incorrectly coded as not having a terminal condition or receiving hospice services, despite documentation indicating that the resident had been on hospice since June 2023 with a terminal diagnosis of malignant neoplasm of the brain. The MDS coordinator, MDS1, admitted to only reviewing physician orders and missing the correct coding due to system updates and oversight. Similarly, Resident 10's MDS was inaccurately coded as not having a terminal condition or receiving hospice services, even though the resident had been on hospice since March 2024 with a terminal diagnosis related to cerebrovascular disease. MDS1 acknowledged the error, citing the same reasons as with Resident 7, including a lack of thorough documentation review and reliance on physician orders alone. For Resident 29, the MDS was incorrectly coded to reflect insulin injections, although the resident was receiving semaglutide (Ozempic) injections for type two diabetes mellitus. MDS1 admitted to not knowing how to capture the injection for MDS assessment and payment purposes, leading to the inaccurate coding. The Director of Nursing and the Administrator expressed their expectation for MDS assessments to be coded accurately, but were unaware of the inaccuracies prior to the survey findings.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which is a deficiency in meeting the residents' needs. Resident 43, who was admitted with end-stage renal disease and a traumatic amputation, did not have a care plan for dialysis or the central venous catheter (CVC) despite having orders for dialysis and a CVC in place. The resident's quarterly Minimum Data Set (MDS) assessment indicated intact cognition and triggered the need for dialysis care planning, yet this was not reflected in the care plan. Interviews with MDS coordinators confirmed the absence of the necessary care plans. Similarly, Resident 47, admitted with acute respiratory failure requiring supplemental oxygen, did not have a care plan addressing oxygen needs, even though the MDS assessment triggered the need for such a plan. Observations confirmed the resident was using oxygen, but the care plan did not reflect this requirement. Additionally, Resident 67, diagnosed with post-traumatic stress disorder (PTSD), lacked a care plan for managing PTSD, despite the MDS assessment indicating the need for it. Interviews with staff confirmed the absence of these care plans, acknowledging that they should have been in place to address the residents' health and psychosocial issues.
Failure to Specify Dosage in Medication Order
Penalty
Summary
The facility failed to ensure a medication order was written to include the proper dosage for a prescribed medication, as observed in the case of a resident admitted with a diagnosis of pain in the right shoulder. The resident was ordered to receive a 5% Lidoderm patch for pain management, but during medication administration, an LPN applied a 4% Lidoderm patch instead. The LPN confirmed the use of the 4% patch, stating it was the only available option covered by insurance. Upon review, it was found that the medication administration record (MAR) did not specify the dosage for the Lidoderm patches. Further investigation revealed that the Nurse Practitioner (NP) intended for the resident to receive 4% patches due to insurance constraints, and she did not include a dosage in the order because the 4% patches were over-the-counter. The NP was unaware of how the 5% dosage appeared in the order. The Director of Nursing (DON) stated that the current standard of practice required all medication orders to include a dosage, highlighting a discrepancy between the facility's policy and the actual practice observed.
Failure to Address Gradual Weight Loss in Resident
Penalty
Summary
The facility failed to adequately assess and address the cause of a continual, gradual, and unintentional weight loss for a resident, identified as R12, who was reviewed for nutrition among a sample of 20 residents. R12 was admitted with multiple diagnoses, including multiple sclerosis and hypertension, and was on a regular diet with pureed texture and thin liquids. Despite a documented gradual weight loss over several months, no significant interventions or assessments were implemented to prevent further weight loss. The facility's policy required monitoring and documentation of weight and dietary intake, with interventions based on identified causes. However, R12's records showed a weight loss of 7.5% over six months, with no documented evidence of an assessment or evaluation by the Registered Dietician (RD) after a referral was made in May 2024. The care plan noted R12 was at risk for weight loss and dehydration, but no dietary recommendations or weight loss plan were documented. Interviews with the RD and Dietary Manager (DM) revealed a lack of communication and documentation regarding R12's weight loss. The RD stated she only intervened in cases of significant weight loss and did not recall being informed of R12's situation. The DM acknowledged providing dietary interview information to the RD but did not document it. The Administrator and Director of Nursing (DON) confirmed that the RD should have identified and implemented interventions for R12's gradual weight loss.
Failure to Monitor Blood Pressure Before Administering Lisinopril
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not adhering to physician-ordered blood pressure monitoring prior to administering lisinopril, a medication used to treat hypertension. The resident, identified as R48, was readmitted with a diagnosis of essential hypertension and had specific physician orders to withhold lisinopril if the systolic blood pressure was less than 100. However, the facility's records showed that blood pressure was inconsistently monitored, with significant gaps in documentation over several months. Despite these gaps, lisinopril was administered daily, even on days when the recorded systolic blood pressure was below the threshold of 100. The facility's policy required the evaluation of medication effectiveness and potential problems, but this was not followed in R48's case. Observations and interviews revealed that the blood pressure monitoring equipment was set to automatically record readings in the electronic medical record, yet this process was not consistently followed. The Director of Nursing confirmed that the expectation was for blood pressure to be recorded if there were specific parameters to follow, and acknowledged that the administration of lisinopril should have been withheld when the systolic blood pressure was below 100. This oversight had the potential to cause adverse consequences for the resident.
Failure to Conduct Ordered Therapy Evaluations
Penalty
Summary
The facility failed to conduct physical and occupational therapy evaluations as ordered by the physician for a resident, identified as R231, who was reviewed for rehabilitation services. R231 was admitted to the facility with diagnoses including type two diabetes mellitus, major depressive disorder, muscle weakness, reduced mobility, and a need for assistance with personal care and continuous supervision. The resident's care plan highlighted a risk for falls due to confusion, deconditioning, and unawareness of safety needs, with interventions including physical therapy evaluation and treatment as ordered or needed. However, there was no documented evidence in the electronic medical record that R231 had been evaluated for these therapies. Interviews conducted during the investigation revealed that R231 had not received the expected rehabilitation services. The resident expressed that she was supposed to be on rehabilitation services, which was the reason for her admission to the facility. The Director of Therapy confirmed that evaluations had not been conducted, citing a misunderstanding that R231 was a long-term care resident and private pay, which led to the omission. The Director of Therapy acknowledged that a quick screening was done, but emphasized that the best practice would have been to perform the evaluations. The facility's Administrator stated that it was his expectation for therapy evaluations to be completed as ordered by the physician.
Failure to Update Care Plan for Resident with Unwitnessed Injuries
Penalty
Summary
The facility failed to revise and update the care plan for a resident who experienced unwitnessed injuries. The resident, who was admitted with multiple diagnoses including vascular dementia with behaviors, major depression, late-onset cerebellar ataxia, and cognitive communication deficits, had bruises on both hands. These bruises were first noted in daily care notes and a nurse's skin check, and were later brought to the attention of the staff by the resident's daughter. An investigation revealed that the bruises were caused by the resident grabbing the wheels of his wheelchair in a manner that led to bruising. Despite the findings, the resident's care plan did not include instructions for staff to provide total assistance with wheelchair use, which was necessary to prevent further injury. The registered nurse confirmed that the care plan lacked this critical information, indicating a failure to update the care plan to reflect the resident's current care needs and treatments. This oversight suggests that the facility may not have been providing the appropriate care to meet the resident's needs.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Fe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa Real | 0.2 mi | — | 56 | 0 |
| Los Alamos Wellness & Rehabilitation | 24.5 mi | ★★★★★ | 7 | 1 |
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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.