Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Fe Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide a resident with oral and written notice of rights, rules, services, and charges at admission. A resident with major depression, HF, pulmonary HTN, and dementia had no signed acknowledgment of resident rights in the record. The RP said she was not informed of the resident’s rights or service details and later discovered the resident had been taken off Lexapro without notification. The ADM confirmed there was no evidence the admission packet or resident rights information had been provided.
Failure to Notify Resident Representative of Medication Discontinuation: The facility did not immediately inform the resident's RP or physician when a resident's Lexapro was discontinued. The resident, who was alert and oriented to name and place, said she did not know she was off her depression medication until her daughter raised concerns about behavior changes, including poor appetite, nighttime waking, and loss of interest. The RP reported she was not notified, had to request the med list to learn the medication had stopped, and said the DON deferred to hospice after the resident's care status changed.
Improper wound care for a resident with a pressure ulcer. An RN removed the old dressing and applied betadine to the wound without first cleansing it with wound cleanser as ordered. The resident had an unstageable pressure ulcer on the right distal medial foot, was dependent for most ADLs, and was always incontinent. The RN stated she could not remember the last wound training and acknowledged not following proper infection control practice; the DON stated the expected process was to cleanse the wound before applying treatment.
Unsecured Medication Carts: Two medication carts were found unlocked and unattended during observation. Medication Cart 200 was left unlocked in Hall 200 near the dining room entrance, and Medication Cart 100 was found unlocked with a drawer partially open outside a resident room. The DON secured one cart, and the ADMN stated an LPN failed to follow facility policy for storing and securing medications.
Failure to perform hand hygiene and change gloves during incontinent care. A CNA provided perineal care to a resident with multiple serious diagnoses, including stroke-related hemiplegia, DM2, morbid obesity, and cancer, while wearing the same gloves across tasks, touching the roommate's nightstand drawer, leaving the room to retrieve supplies, and removing gloves without hand hygiene. The CNA acknowledged he should have changed gloves, and the DON stated hand hygiene was expected when entering or leaving a resident's room and between tasks.
Activity program was not directed by a qualified professional because the AD did not complete the required annual 8-hour CE training through the state-approved AD training website. Record review showed no documentation of the required CE hours, and interviews confirmed the AD believed facility online training would count, while HRD and ADMN acknowledged the requirement was separate from facility in-services.
A CNA did not change gloves or perform hand hygiene while providing incontinence care to a resident with a history of serious infections, handling clean items with soiled gloves and only washing hands after care was completed. The DON confirmed that staff are trained and expected to follow standard infection control precautions, which were not observed in this instance.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to accepted professional standards, as observed by surveyors during their review of documentation and information handling practices.
The facility failed to adhere to professional standards for food service safety, as observed in the improper labeling and storage of food items in both dry storage and refrigerators. Items such as powdered milk, noodles, and bacon slices were found without proper labels or dates, posing a risk for foodborne illnesses. Interviews with the DM, ADMIN, and Dietician highlighted a lack of attention from staff and a need for better education on labeling practices.
The facility failed to ensure residents' rights to receive unopened mail and packages, as reported by ten residents who experienced their mail being opened by staff without consent. Interviews revealed that the AD delivered mail but took packages to the ADON for inspection, leading to a violation of resident rights. The DON and ADMN acknowledged the issue, highlighting a lack of proper procedures and communication among staff.
The facility failed to remove expired medications from a medication cart and did not document temperature monitoring for two medication storage refrigerators. A liquid oral supplement marked as expired was found on the 200 Hall Medication Cart, and temperature logs for refrigerators storing medications and lab specimens were incomplete. The DON and RN A acknowledged these oversights, which contradict the facility's policy on drug storage and expiration management.
Failure to Provide Resident Rights Notice at Admission
Penalty
Summary
The facility failed to inform a resident, both orally and in writing in a language the resident understands, of her rights and all rules and regulations governing resident conduct and responsibilities during her stay. Review of the resident’s record showed no signed acknowledgment that she was informed of her rights and responsibilities prior to or at admission. The resident was admitted with diagnoses including major depression, heart failure, pulmonary hypertension, and dementia, and was observed lying in bed, alert, and oriented to name and place. She stated she did not know she was not receiving her major depression medication until her daughter informed her, and she reported no interest in activities because she was depressed. The resident’s responsible party stated the resident’s behavior was not normal, describing refusal of meals, waking at night, and loss of interest in everything. She said she discovered the resident was not taking Lexapro after requesting the medication list and stated the facility did not notify her before discontinuing the medication. She also stated she did not receive notice of rights and services during admission in oral or written form and had not signed admission documents. The administrator stated there was no evidence the resident was provided written information regarding resident rights on admission or after, that the facility did not have an admission packet for the resident, and that the packet could not be found.
Failure to Notify Resident Representative of Medication Discontinuation
Penalty
Summary
The facility failed to immediately notify the resident's physician and the resident's representative when the resident's depression medication, Lexapro 20 mg by mouth each morning, was discontinued. Resident #1 was observed lying in bed, alert and oriented to name and place, and stated she did not know she was no longer receiving her major depression medication until her daughter told her. She also stated she had no interest in participating in activities because she was depressed. Record review showed Resident #1 received Lexapro from 04/01/26 through 05/07/26, and the resident's responsible party stated the resident was taken off the medication without being informed. The responsible party reported changes in the resident's behavior, including refusing meals, waking at night, and losing interest in everything, and said she had to request the medication list to discover the resident was not taking Lexapro. During interview, the DON stated she was not aware the responsible party had not been informed when the depression medication was discontinued and said the resident had been transferred to hospice care, with all medications discontinued because hospice determined what was required for ongoing care.
Improper Wound Care for a Resident With a Pressure Ulcer
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for a resident with an unstageable pressure ulcer on the right distal medial foot. The resident was a 63-year-old female admitted with diagnoses including urinary tract infection, drug induced subacute dyskinesia, intermittent explosive disorder, and dementia. Her MDS showed she was dependent on staff for most ADLs, required one-person assistance with transfers, and was always incontinent of bowel and bladder. Her care plan identified the pressure ulcer and noted risk for infection, pain, and decline in functional abilities, with a goal for the ulcer to show signs of healing. During observed wound care, RN G washed hands, donned gloves, removed the old dressing, and changed gloves, but applied betadine to the wound without first cleansing it with wound cleanser as ordered. The physician order directed staff to cleanse the unstageable wound on the right medial distal foot with wound cleanser and then apply betadine every shift. RN G later stated she could not remember the last time she received wound training and acknowledged she did not follow proper infection control practice during the wound care. The DON stated it was expected practice to cleanse the wound before applying treatment and to prepare a clean field, cleanse the wound, and apply treatment after drying the wound.
Unsecured Medication Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments on 2 of 8 medication carts reviewed for pharmacy services, specifically Medication Cart 100 and Medication Cart 200. During an observation and interview on 4/14/2026 at 6:28 AM, Medication Cart 200 was found unlocked and unattended against the wall of Hall 200 beside the entrance into the dining room. The DON was present in the hallway, and there were no other staff in the area. The DON locked the cart and stated LVN D was responsible for that medication cart. During an observation on 4/14/2026 at about 6:55 AM, Medication Cart 100 was found unlocked with a drawer partially opened outside of Room [ROOM NUMBER]. The resident door was closed, and the medication cart was unattended. LVN D was observed exiting Room [ROOM NUMBER] and refused to be interviewed. She then pushed the medication cart against the wall at the entrance of the 200 hall. During an interview on 4/14/2026 at 8:40 AM, the ADMN stated LVN D had failed to meet and maintain facility policy and standards for storing and securing medications. The facility policy titled Medication Storage, dated 1/20/2021, stated that all drugs and biologicals would be stored in locked compartments and that only authorized personnel would have access to the keys.
Failure to Perform Hand Hygiene and Change Gloves During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for Resident #86 during incontinent care. Resident #86 was a male admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction, depressive episodes, type 2 diabetes mellitus with hyperglycemia, morbid obesity, dysarthria and anarthria, malignant neoplasm of the duodenum, and frontal lobe and executive function deficit following cerebral infarction. During an observation, CNA-C put on gloves without performing hand hygiene before providing incontinent care. CNA-C assisted the resident with positioning, lowered his pants, removed the mechanical lift pad, and used wet wipes to clean the peri-area for a brief change. CNA-C then went around the privacy curtain and opened a drawer of the roommate's nightstand to look for a brief. CNA-C returned to the bedside, repositioned the resident, left the room through the hallway to a linen cart with gloved hands to retrieve washcloths, and returned to complete care. CNA-C removed gloves when leaving the room to get a urinal without using hand sanitizer or washing his hands. In interview, CNA-C stated he should have changed gloves during the care and acknowledged he did not do so. The DON stated hand hygiene was expected when entering or leaving a resident's room and in between tasks or when hands are dirty.
Activity Director Lacked Required Annual CE Training
Penalty
Summary
The facility failed to ensure that the activity program was directed by a qualified professional who completed a state-approved training course. Record review of personnel files showed that the Activity Director, hired on 04/02/2023, did not provide documentation of the required 8-hour annual continuing education training for Activity Directors. The job description for the Activity Director reflected that the position required successful completion of a state approved and certified course of instruction in patient activities. During interviews on 04/15/2026, the Activity Director stated she did not currently have her 8 CE hours for Activity Director and believed her facility online training hours would count toward that requirement, but she had just been told they did not. The HRD stated she learned the prior day that the Activity Director did not have her yearly 8 hours when she asked for a copy of the training. The ADMN stated he was the Activity Director's direct supervisor and that staff are expected to keep up with required training for their certifications, and he acknowledged that the 8-hour course is required outside of facility training.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection control procedures while providing incontinence care to a female resident with a history of methicillin susceptible and resistant staphylococcus aureus infections, bacteremia, and breast cancer. During the observed care, CNA A washed her hands before donning gloves and removed a soiled brief, but did not change gloves or perform hand hygiene after cleaning the resident and before handling a clean brief. The gloves were visibly soiled with urine, and CNA A continued care and handled clean items without changing gloves or washing hands. She only removed her gloves and washed her hands after completing care and handling trash. In an interview, CNA A acknowledged she should have changed gloves before handling the clean brief and recognized the risk of cross-contamination, attributing her lapse to being nervous. The Director of Nursing (DON) confirmed that infection control training is provided monthly and that staff are expected to follow standard precautions, including hand hygiene and glove changes. The facility's infection control policy requires adherence to standard precautions and proper hand hygiene, which were not followed during the observed incident.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the dry storage area, several food items were found improperly labeled or not labeled at all, including large containers of powdered milk, bags of breadcrumbs, egg noodles, spaghetti noodles, lasagna noodles, vanilla wafers, powdered sugar, and coconut flakes. Additionally, during an observation of the refrigerators, items such as bacon slices, grape jelly, and thickened sweet tea were found open and without proper labeling or dating. These deficiencies were noted during a survey of the facility's kitchen. Interviews with the Dietary Manager (DM), the Administrator (ADMIN), and the Dietician revealed that the facility's policy requires all food products to be labeled with a received date and a used by date. The DM acknowledged that the failure to properly label and date food items could lead to foodborne illnesses, and attributed the issue to staff not paying attention. The ADMIN expressed that it was the DM's responsibility to ensure proper labeling and dating, while the Dietician, who visits the facility every six weeks, noted that the DM was new and working on educating the kitchen staff. The facility's policies on food storage, both dry and cold, align with FDA Food Code guidelines, but were not adhered to in this instance.
Violation of Resident Rights: Unopened Mail and Packages
Penalty
Summary
The facility failed to ensure that residents had the right to receive mail and packages unopened, which is a violation of resident rights. During a confidential resident group meeting, ten residents reported that their mail and packages had been opened by staff without their consent. They also mentioned that mail was not delivered daily and lacked a set schedule, with some mail being placed in their rooms without their knowledge. This practice led residents to feel that their rights were being violated, as they were not present when their mail was opened, nor were they asked for permission. Interviews with facility staff revealed a lack of clarity and adherence to proper procedures regarding mail handling. The Activity Director (AD) stated that she delivered mail daily but took packages to the Assistant Director of Nursing (ADON) to be opened, citing concerns about prohibited items such as medications or tobacco products. The ADON confirmed that packages were brought to his office and opened if they were suspected to contain medications. The Director of Nursing (DON) and the Administrator (ADMN) both acknowledged that mail should not be opened without resident permission and that the practice was a violation of resident rights. However, there was a lack of awareness and communication among staff about the issue, leading to the deficiency.
Expired Medications and Incomplete Temperature Logs Found
Penalty
Summary
The facility failed to adhere to pharmacy procedures, resulting in expired medications being found on the 200 Hall Medication Cart and incomplete temperature logs for medication storage refrigerators. During an observation, a bottle of liquid oral supplement marked as opened on 06/01/24 and expired on 07/27/24 was discovered in the bottom drawer of the medication cart. RN A, who was using the cart, acknowledged that the bottle should have been discarded earlier and confirmed that no patients on the 200 Hall had orders for this supplement. The Director of Nursing (DON) expressed surprise at the presence of expired medications, despite regular audits by a pharmacy consultant. Additionally, the facility failed to document temperature monitoring for two medication storage refrigerators since 02/12/25. Refrigerator #1, which stored lab draws and urine specimens, showed a current temperature of 36 degrees, while Refrigerator #2, containing medications such as inhalants and narcotics, showed a temperature of 38 degrees. RN B admitted uncertainty about why the logs were incomplete, and the DON stated that it was the night nurse's responsibility to check and log temperatures nightly. The facility's policy mandates proper storage temperatures and the immediate withdrawal of expired or deteriorated drugs.
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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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Nursing homes near Weatherford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holland Lake Rehabilitation And Wellness Center | 0.2 mi | ★★★★★ | 8 | 0 |
| Hilltop Park Rehabilitation And Care Center | 0.3 mi | ★★★★★ | 3 | 0 |
| College Park Rehabilitation And Care Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Peach Tree Place | 1.1 mi | ★★★★★ | 1 | 0 |
| Avir At Keeneland | 2 mi | ★★★★★ | 9 | 0 |
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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 August 2026) and official state health department websites.