Santa Fe Health & Rehabilitation Center

Inspectors wroteBased on observations, interviews and record review the facility failed to inform residents, both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for 1 of 3 residents (Resident #1) reviewed for resident rights. The facility failed to maintain written acknowledgment that Residents #1 was informed prior to or at admission of their rights, the rules governing resident conduct, and their responsibilities during their stay at the facility This deficient practice could place residents at risk of not being aware of their rights, responsibilities, the facility's policies on admission.

Inspectors wroteBased on interviews and record review, the facility failed to immediately notify the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was an accident involving the resident for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to inform the Resident #1 responsible party (RP) that her depression medications were discontinued.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #4) reviewed for wound care. RN G failed to use standard, proper technique and process while providing wound care for Resident #4. RN G did not cleanse the wound before applying physician ordered treatment. These failures placed residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments on 2 of 8 (Medication Cart 100 and Medication Cart 200) medication carts reviewed for pharmacy services. The facility did not ensure medication carts 100 and 200 were secured and locked when unattended. This failure could place all residents at risk of drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 3 residents (Resident #86) observed for infection control. Facility staff (CNA-C) failed to sanitize, wash hands, and/or change gloves while providing perineal care to Resident #86. This failure could place all residents at risk of infectionFindings included:Record review of Resident #86's Electronic Face sheet dated 04/15/26 revealed he was a [AGE] year-old male. He was admitted to the facility on [DATE]. Diagnoses included: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the activity program was directed by a qualified professional who completed a training course approved by the state for 1 of 1 (AD) activity director reviewed for training. The facility Activity Director (AD) failed to take her annual 8 hours of continuing education course work for Activity Director through the state AD training website. These failures could place residents at risk of inadequate activities from incompetent/untrained staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #5) reviewed for pharmaceutical services, in that: RN A failed to reorder medication for Resident #5 before his supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 5 (Resident #5) residents reviewed for resident records. RN A failed to ensure she documented treatment orders on the MAR or progress notes when not administered for Resident #5. This failure could place residents at risk of having errors with their care and treatment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator and dry storage This failure could place residents that eat out of the kitchen at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents unopened for the entire facility reviewed for resident rights. The facility failed to ensure that residents received packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pharmacy procedures were followed for 1 of 4(200 Hall Medication Cart) medication carts, and 2 of 2 medication refrigerators reviewed for pharmacy services. The facility failed to remove expired medications from the 200 Hall Medication Cart. The facility failed to document monitoring of temperatures in the medication storage refrigerators in the medication room. These failures could place residents at risk of receiving ineffective therapeutic doses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (LVN-B, CNA-D, CNA-C) reviewed for infection control procedures. The facility failed to ensure the LVN-B perform proper hand hygiene before and after providing resident care. The facility failed to ensure the CNA-D perform proper hand hygiene before and after removal of gloves. The facility failed to ensure the CNA-C performed incontinent care in accordance with facility policy. These failures could place residents at risk for the transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services The facility failed to prevent the following: 1. Vinyl mesh liner was used to cover stainless steel surfaces on shelves and in drawers. 2. Floor tile grout was soiled with a dark colored build-up and dried food throughout the kitchen. 3. The interior surface of the microwave oven was soiled with dried food and grease. 4. The three-door freezer unit for storing breakfast foods and desserts had a temperature above zero and food items were not frozen solid. 5. The sink for the garbage disposal leaked and a bucket was on the floor beneath it to catch dripping water. 6. Floor tiles were missing near the dish machine. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 3 residents (Resident #44) reviewed for enactment of advance directives. The facility failed to ensure Resident #44 had the Out of Hospital Do Not Resuscitate (OOH-DNR) documentation in his electric record. This failure could put residents at risk of not having their OOH-DNR honored, resulting in receiving medical treatment they did not desire.

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 2 residents (Resident #27) whose records were reviewed for resident assessment, in that: Resident #27 had a PASRR evaluation dated 2/18/2020 which documented he was positive for mental illness. His annual MDS assessment dated [DATE] documented he had no Level II PASRR conditions. This failure placed the resident at risk for not receiving mental health services as needed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #76) reviewed for PASRR Level 1 screenings. The facility did not correctly identify Resident #76 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services .

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents were free of a med error rate of 5% or greater (8%) for 2 (Residents #300 and #49) of 6 residents reviewed for medication administration. 1. The facility failed to ensure RN F primed (removing air bubbles from the needle to ensure that the needle is open and working) insulin pen for Resident #300 before administering Lantus insulin. 2. The facility failed to ensure RN G primed the insulin pen for Resident #49 before administering Novolog insulin. 3. The facility had a 8% medication error rate based on 2 errors out of 25 opportunities, which involved 2 of 6 residents reviewed for pharmacy services. This failure placed residents at risk of incorrect doses of medications.

Inspectors wroteBased on interview and record review , the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 3 residents (Residents #14 and #66) whose record were reviewed for accurate and complete documentation. The facility failed to prevent the following: 1. The facility failed to ensure Resident #14's Out of Hospital - Do Not Resuscitate Order form was signed as by the resident and two witnesses in the box at the bottom of the form. 2. The facility failed to ensure Resident #66's Out of Hospital - Do Not Resuscitate Order form included a date for the physician's stamped signature, the physician's printed name, or the physician's license number. [...]