Santa Fe Care Center

Inspectors wroteBased on observation and interview, the facility failed to secure and lock medication and wound care cart leaving it open for easy access. This failure had the potential to affect all 103 residents that resided in the facility. This deficient practice is likely to cause harm if a resident were to access and consume unprescribed medications.

Inspectors wroteBased on and record review, observation, and interviews, the facility failed to maintain a safe and comfortable environment for all residents and occupants when staff failed to: - Maintain the oxygen tanks and cylinder storage in compliance with National Fire Protection Association (NFPA) 99 requirements. - Maintain the portable fire extinguishers (PFE) clearance to be readily accessible and immediately available, This failure had the potential to affect all facility occupants. If staff fail to maintain a safe environment, then the residents and occupants could find themselves in an emergency situation which could endanger their health and safety.

Inspectors wroteBased on observation and interview, the facility failed to protect residents' personal health information (PHI; identifiable health information) when staff left a document containing PHI unattended on top of a nursing cart in hallway. This failure had the potential to affect 16 residents out of 104 residents residing in the facility. This deficient practice is likely to result in passerby having unauthorized access to sensitive information, placing residents' privacy at risk.

Inspectors wroteBased on interview and record review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when staff failed to report and investigate a resident elopement for 1 (R #1) of 2 (R #1 and R #2) residents. If the facility does not report and conduct a thorough investigation when residents elope, then residents are likely to be at risk for harm and possible injuries.

Inspectors wroteBased on record review and interview, the facility failed to prevent significant medication errors for 3 (R #2, R #3, and R #9) of 5 (R #2, R #3, R #4, and R #5) residents reviewed for medication errors when the facility did not administer night medications on 03/30/26. This deficient practice is likely to result in residents having adverse effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review and interview, the facility failed to report incidents involving allegations of abuse to the State Agency for 2 (R #2 and R #3) of 3 (R #2, R #3, and R #9) residents reviewed for abuse. If the facility fails to report allegations of abuse to the State Agency, then the State Agency is unable to ensure residents are free from abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents from the potential for accidents and hazards for 2 (R #s 24 and 71) of 2 (R #s 24 and 71) residents reviewed for falls when the facility did not provide fall mats as ordered by a physician and/or care planned. If the facility is not using fall mats for residents' safety as ordered by a physician, then this deficient practice could likely result in residents getting injured in avoidable accidents and putting residents at risk of serious injury, serious harm, and possibly death.

Inspectors wroteBased on record reviews and interview, the facility failed to complete the required pharmacy review of resident medications for 5 (R #s 8, 9, 10, 11, and 71) of 7 (R #s 4, 8, 9, 10, 11, 20, and 71) residents reviewed for pharmacy reviews when the facility failed to: -Assure that residents' medications were reviewed by a licensed pharmacist monthly from August 2024, through October 2025 for R #s 10, 11, and 71 -To carry out pharmacy recommendations that were approved by the provider for R #s 8, and 9 These deficient practices are likely to result in residents receiving medications that are unnecessary for their health.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 1 (R #1) of 1 (R #1) resident reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the Providers (Physicians and Nurse Practitioners) and the Director of Nursing (DON) of a change in condition in which a resident experienced a large left forearm injury (skin tear- acute wound that is caused by mechanical force or a traumatic injury) for 1 (R #4) of 1 (R #4) residents reviewed for injury. This deficient practice likely resulted in R #4's injury becoming worse with increased bleeding due to the resident taking a blood thinner, and a delay going to the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to monitor and provide appropriate interventions for 1 (R #4) of 3 (R #4, #5, and #6) residents reviewed for injury: 1. When the facility failed to provide proper wound care for R #4's left forearm laceration. 2. When the facility nurses failed to communicate the severity of R #4's left forearm laceration to other nursing staff. 3. When the facility failed to re-assess R #4's left forearm laceration for approximately 12 hours. These deficient practices likely resulted in R #4's left forearm laceration becoming worse with additional bleeding, that required hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, nail care, and eating) assistance for toenail care by the facility staff for 1 (R #4) of 1 (R #4) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident medical records were complete and accurate for 3 (R #1, #2 and #3) of 3 (R #1, #2 and #3) residents reviewed. This deficient practice will likely result in staff not knowing residents' daily care events, changes, and needs.

Inspectors wroteBased on record review and interview, the facility failed to report an investigation regarding allegations of an injury of unknown origin for 1 (R #4) of 1(R #4) residents reviewed for injuries and wounds. If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #4) of 1 (R #4) residents reviewed when staff failed to update the care plan to include anticoagulant (blood thinner) use. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to sanitize glucometers between use during fingerstick blood sugar tests (FSBS) in a manner that prevented cross-contamination for three (Resident (R) 58, R48, and R232) of three residents observed receiving FSBS tests; ensure enhanced barrier precautions (EBP) were in place as required for 10 of 10 sampled residents (Resident (R) 231, R56, R29, R42, R8, R10, R21, R131, R42, and R47) who had indwelling urinary catheters, suprapubic catheters, and/or feeding tubes and were reviewed for EBP out of a total sample of 20; update infection control policies and procedures on an annual basis; and have control measures in place to monitor their water safety management program. This had the potential to affect 87 of 87 residents who resided at the facility. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to have an Infection Preventionist (IP) that had completed specialized training in infection prevention and control. This deficient practice had the potential to allow staff to go without the proper knowledge and training of infection control practices for 87 census residents.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen (O2) concentrators had a filter or dust free filters on the inlet where the air came into the machine for five of five residents (Resident (R) 7, R19, R16, R47, and R132) of 20 sample residents. This deficient practice had the potential to allow an increased chance of infection and unnecessary respiratory treatment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5% with five errors out of 25 opportunities which resulted in a 20% error rate for three of three residents (Resident (R) 50, R48, and R56) observed for medication administration out of a total of 87 residents. The facility failed to ensure Lidoderm patches (used for neuralgic pain) were applied or removed as ordered by the physician for R50, levothyroxine (used to treat hypothyroidism) and lisinopril (used to treat hypertension) were administered as ordered by the physician for R48, and Vitamin B-12 was administered in the correct dosage for R56. This failure had the potential to affect resident medication safety.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to have written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) CMS [Centers for Medicare and Medicaid Services]-10055 for one of three residents (Resident (R) 27) reviewed for beneficiary notices of 20 sample residents. The facility failed to have written documentation to indicate R27 or their legal representative were notified in writing of the SNFABN, the reason why Medicare might not pay for services, and the estimated daily cost the resident would be responsible for should they choose to receive skilled services. By not having written documentation, the resident was unable to make an informed decision and was unaware of additional costs and services when skilled services are ending.

Inspectors wroteBased on observation, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Significant Change MDS Minimum Data Set was completed within 14 days of a significant change for one of one resident (Resident (R) 10) receiving hospice services of 20 sample residents. Specifically, R10 was admitted to hospice services on 03/18/24 and no significant change MDS was completed within 14 days of the significant change. By not ensuring completion of a significant change MDS, this failure could potentially place the resident at risk for unmet care needs being addressed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete a quarterly assessment for one of one resident (Resident (R) 43) reviewed for completion of Minimum Data Set (MDS) assessments out of 20 sample residents. The facility was overdue by 25 days in completing the quarterly assessment.

Inspectors wroteBased on observations, record reviews, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code the Minimum Data Set (MDS) for two of three residents (Residents (R) 7 and R10) receiving hospice services and one of three residents (R29) receiving Insulin of 20 sampled residents. By not ensuring the accuracy of the MDS these failures could potentially place the residents at risk for care needs not being addressed.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure a comprehensive care plan was developed for three of 20 sample residents (Resident (R) 43, R47, and R67) reviewed for care plans to include dialysis with a central venous catheter (CVC) for R43, oxygen for R47, and Post Traumatic Stress Disorder (PTSD) for R67. This deficient practice had the potential for residents to not receive the care and treatment they needed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication order was written to include proper dosage for the prescribed medication per current standards of practice for one of three residents (Resident (R) 50) observed for medication administration out of a total of 87 residents. This had the potential to cause residents to receive the wrong dosage of ordered medications.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to assess the cause of a continual, gradual, and unintentional weight loss and failed to identify and implement interventions to prevent further weight loss for one of four residents (Resident (R) 12) reviewed for nutrition out of 20 sample residents. This had the potential to contribute to a significant to severe weight loss for R12.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the resident did not receive an unnecessary medication when they failed to perform physician ordered blood pressure monitoring prior to the administration of lisinopril (a medication used to treat hypertension) and failed to withhold the blood pressure medication with low blood pressure readings according to the physician ordered parameters for one of five sampled residents (Resident (R) 48) reviewed for unnecessary medications out of 20 sample residents. This had the potential to cause R48 to suffer adverse consequences including hypotension.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to conduct physical and occupational therapy evaluations as ordered by the physician for one of one resident (Resident (R) 231) reviewed for rehabilitation services out of 20 sample residents. This had the potential to cause a physical decline for R231.

Inspectors wroteBased on record review and interview, the facility failed to revise and update the care plan for 1 (R #1) of 1 (R #1) residents reviewed for unwitnessed injuries. If the facility is not updating the care plan to reflect the resident's current care needs and treatments, then the facility may not be providing the appropriate care to meet the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #4) of 2 (R #'s 4 and 6) residents received treatment and care in a timely manner and in accordance with professional standards of practice when R #4 experienced difficulty swallowing and did not eat or drink for multiple days, experienced increased lethargy (a state of sleepiness or deep unresponsiveness and inactivity), respiratory distress, and hypoxia (low oxygen in the blood). If the facility is not monitoring for residents' change in condition, residents are likely at risk of inadequate or delayed treatment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure they had sufficient staff to meet the needs of 11 (R #2 through #12) of 11 (R #2 through #12) residents who resided in the facility that required a minimum of two staff members to provide a safe resident transfer. This deficient practice is likely to negatively impact resident safety and comfort.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #'s 4 and 5) of 2 (R #'s 4 and 5) residents reviewed by not updating the care plan to include current wounds and wound care. This deficient practices is likely to result in residents care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received the necessary treatment and services to prevent the development of pressure ulcers (skin damage which results from unrelieved pressure on the body) for 2 (R #'s 4 and 5) out of 2 (R #'s 4 and 5) residents reviewed when staff failed to: 1. Receive a wound care treatment order, provide wound care treatment, and communicate a new wound for R #4. 2. Receive a wound care treatment order and provide wound care treatment for R #5. This deficient practice is likely to result in residents developing pressure ulcers and in wounds worsening without proper treatment and communication.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was accurate for 3 (R #'s 1, 4, and 6) of 3 (R #'s 1, 4, and 6) residents reviewed when staff failed to: 1. Document embolic stockings (stockings used to prevent blood clots in lower extremities) use for R # 2. Document a daily skilled progress note and nursing progress note the same day R #4 was sent to the ER (Emergency room). 3. Document a daily skilled progress note and nursing progress note the same day R #6 was sent to the ER. This deficient practice is likely to result in staff confusion as to the services and treatment provided.

Inspectors wroteBased on record review and interview, the facility failed to notify the provider or Emergency Contact (EC) for 1 (R #6) of 1 (R #6) residents reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider or EC when the resident experiences a change of condition, then it is likely the provider or EC are unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of care for 1 (R #6) of 4 (R #s 2, 3, 6, and 7) residents reviewed for care when staff failed to ensure the resident was sent out to the emergency room (ER) in a timely manner. If the facility is not sending residents to the emergency room (ER) as ordered then residents are likely to not get the care they need.

Inspectors wroteThis is a repeat deficiency from a survey dated 10/20/22 Based on record review and interview, the facility failed to ensure residents received appropriate pain management for 4 (R #'s 23, 37, 86, and 183) of 4 (R #'s 23, 37, 86, and 183) residents by: 1. Failing to asses and administer pain medication as needed and as ordered for R #'s 23, 37, and 86. 2. Not completing pain assessments for R #183. This deficient practice likely resulted in R's #23 and 86 experiencing severe pain and causing unnecessary distress without timely relief.

Inspectors wroteBased on record review and interview, the facility failed to ensure that they had sufficient staff to meet the needs of all 27 residents residing in Wing 2 and Wing 3 when a Registered Nurse wasn't available to administer medications for residents for (6) hours. These deficient practices likely resulted in R #86 not receiving scheduled pain medication resulting in unnecessary pain.

Inspectors wroteBased on observation and interview, the facility failed to: ensure medications were stored properly, medication carts were locked and secured when not in use, and ensure that medications were not left on bedside tables in residents' rooms. These deficient practices are likely to result in resident injury, through dosing with medications that have been improperly stored, having access to medications not prescribed for them, and possible overdose.

Inspectors wroteBased on observation and interview, the facility failed to provide safe food preparation for all 82 residents as listed on the CMS 672 (Resident Census and Conditions of Residents) provided by the Administrator on 05/15/23, that could receive meals prepared in the kitchen. This failure could potentially cause food borne illnesses to be spread throughout the facility due to the unsanitary conditions. All 82 residents may be affected because they all get served eggs for breakfast

Inspectors wroteBased on observation, interview, and record review, the facility failed to reasonably accommodate resident needs and preferences for 2 (R #'s 10 and 97) of 2 (R #'s 10 and 97) residents reviewed by: 1. Providing R #10 an assisted device used for beverages (sippy cup) without orders and asking R #10's preference. 2. Not honoring R #97's right to choose his own physician or canceling/re-scheduling R #97's physician appointment. If the facility is not honoring resident preferences, then residents are not able to make choices about aspects of their lives that are important to them. This could ultimately affect the residents' overall quality of life and lead to a loss of independence.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the care plan had been revised for 1 (R #1) of 1 (R #1) residents reviewed by not updating the care plan to include oxygen (O2) use. This deficient practices is likely to result in residents care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #'s 65 and 95) of 2 (R #'s 65 and 95) residents by: 1. Not following physician orders for wound care for R #65. 2. Providing R #95 an antidepressant without depression indications. If the facility is not providing wound care as ordered, and prescribing medications without indications, then residents are likely to not receive the therapeutic benefits as needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #73) of 2 (R #11 and 73) residents reviewed for dental care obtained routine and as needed dental care. If the facility is not ensuring that residents with identified dental issues receive timely dental care, then residents are likely to experience tooth decay, tooth pain, and difficulty chewing; which could also affect their nutritional well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was communication (exchanging of information) in the resident's record indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for 1 (R #37) of 1 (R #37) resident reviewed for Hospice Services. This deficient practice could likely lead to the resident not receiving the services needed due to lack of collaboration (to work jointly) and communication between the facility and hospice provider.

Inspectors wroteBased on observation and interview, the facility failed to use infection control protocols for the storage and cleanliness of nebulizers (a device that is used to administer medication in the form of a mist inhaled into the lungs) and a glucometer (a portable machine used to check blood sugar levels) for 2 (R #1 and 12 ) of 2 (R #1 and 12) residents reviewed for infection control. If the facility is not using proper infection control protocols, residents are likely to be exposed to airborne pathogens and infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNA's) received the required in-service training of no less than 12 hours per year for 2 (CNA #12 and CNA #13) of 3 (CNA #12, CNA #13, and CNA #14) CNA's randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 (R #87) of 1 (R #87) resident's records contained current documentation of code status (a directive regarding a resident's resuscitation [the action or process of reviving someone from unconsciousness or apparent death] wishes should a life threatening event occur). This deficient practice has the potential to deny residents the fulfillment of their end of life medical care choices and could result in unnecessary suffering for the resident and their significant others.

Inspectors wroteBased on record review and interview, the facility failed to document efforts to resolve a resident grievance for 1 (R #74) of 1 (R #74) resident with complaints against staff. This deficient practice is likely to result in the residents' rights not being honored.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 4 (R #'s 4, 17, 37, and 44) of 4 (R #'s 4, 17, 37 and 44) resident reviewed for Minimum Data Set (MDS) assessments, had MDS documents completed, submitted, and finalized in a timely manner. If MDS assessments are not completed and submitted in a timely manner, then residents are likely to receive less than optimal care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the discharge MDS (Minimum Data Set) Assessment was accurate regarding change of condition and discharge for 1 (R #81) of 1 (R #81) resident reviewed for facility discharges. This deficient practice is likely to cause the resident to not receive the care and services needed to attain or maintain their highest practicable well-being.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review of 1 Certified Nurses Aide (CNA #14) of 5 (Certified Nurses Aide #12, #13, #14, #15, #16) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that psychotropic medication (medication used to treat mental health conditions) orders included the appropriate indication (use for the ordered medication) and that the resident had an appropriate diagnosis (medical condition) for 1 (R #95) of 1 (R #95) resident reviewed for unnecessary psychotropic drugs. This deficient practice could likely place R #95 at an increased risk for undesirable side effects (increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a medical record were accurate for 1 (R #95) of 1 (R #95) resident reviewed for accurate documentation by not accurately documenting the timeliness of R #95's medication administration. This deficient practice is likely to result in staff confusion as to the services and treatment needing to be provided to residents.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the freezer were properly stored. 3. Ensuring the restorative (having the ability to restore health, strength, or a feeling of well-being) freezer was clean. These deficient practices are likely to affect all 55 residents listed on the resident census list provided by the Administrator (ADM) on 03/20/22. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 3 (R #16, 20 and 52) of 3 (R #16, 20 and 52) residents reviewed by: 1. Not assisting residents to shower per their requested schedule 2. Not providing visitors a restroom within the building likely reducing the amount of time a visitor can stay and visit. These deficient practices are likely to result in the resident's life style, personal choices, needs and preference not being met, resulting in boredom, depression, poor hygiene and loss of dignity.

Inspectors wroteBased on record review and interview, the facility failed to ensure that grievances received by both the Resident Council and individual residents are responded to timely for 2 (R #39 and 52) of 2 (R #39 and 52) residents reviewed. If the facility is not ensuring that grievances are responded to timely, then residents are likely at risk of continued repeat concerns and feeling as though their concerns are unimportant to the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care for 2 (R #39 and 56) of 2 (R #39 and 56) residents reviewed by: 1. Not labeling and dating oxygen (O2) tubing per physicians orders for R #39. 2. Administering O2 without physician orders for R #56. If the facility is administering O2 without physician orders, and not following physician orders to label and date O2 tubing, then residents are likely to not get the therapeutic results of medication/treatment needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 1 ( R #54) of 1 (R #54) resident reviewed for weight loss by not: 1) Monitoring for weight loss following 8.5% weight loss in one month for R #54 2) Identifying weight loss for R #54 and implementing interventions. This deficient practice is likely to result in continued weight loss and resident decline.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #48) of 1 (R #48) resident's Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were accurately reflected in the Electronic Medical Record (EMR) (a medical record which is accessible by computer) for resident. This deficient practices are likely to result in residents wishes for emergency medical care not being honored.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a homelike environment, for 1 (R #39) of 1 (R #39) residents reviewed for homelike environment, by not maintaining an environment that is clean and free of clutter. If the facility fails to maintain resident rooms in a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues.