Santa Fe Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision to a known high-risk resident (1) for elopement (an unsupervised, undetected, and unauthorized departure from the facility). As a result, Resident 1 left the facility unnoticed through the room window for the second time. This failure exposed Resident 1 to potential harm, including cold weather environmental exposure, physical injuries from accidents, and medical emergencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for one resident (1) who was a known high risk for elopement (an unsupervised, undetected, and unauthorized departure from the facility). As a result, Resident 1 left the facility unnoticed and was gone for seven days. This failure had the potential harm for Resident 1 from environmental exposure from cold weather, physical injuries from accidents, and medical emergencies.

Inspectors wroteBased on observation, interview, and record review, the facility did not accurately assess and code the Minimum Data Set (MDS-Federally required assessment) for one of three residents (Resident 1) reviewed for pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). As a result, Resident 1's MDS was sent to the federal database with inaccurate information about Resident 1's health status. Cross-Reference F686Findings:A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] and discharged to the hospital on 8/13/25 with diagnoses which included a history of Paroxysmal Atrial Fibrillation (describes a fast, irregular heartbeat that only lasts a few hours or days). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, stage, and provide timely wound care interventions for pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), for two of three residents (Resident 2 and Resident 3) reviewed when:1. Resident 2's initial admission assessment documented a rash on the sacrum (triangular-shaped bone located at the base of the spine that forms the posterior wall of the pelvis) and was staged later as a Stage II pressure ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the sacrum, (one month and three weeks) after admission on [DATE] by a Licensed Nurse and Nurse Practitioner (NP).2. Resident 3's initial admission assessment did not properly identify a stage III pressure ulcer (full-thickness loss of skin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and ensure timely reporting of an elopement to CDPH (California Department of Public Health) for one of three sampled residents (Resident 1) reviewed during a complaint investigation. This deficient practice placed Resident 1 at risk for serious injury, harm or death due to unsafe wandering, potential exposure to traffic-related injuries, falls, or becoming lost in the community.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure Resident 1's preference for a female provider was respected. This failure had the potential to cause psychological effect to Resident 1.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to provide necessary services to maintain personal hygiene for 3 (Residents #16, #73, and #58) of 5 sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure residents had access to their personal funds after hours and on weekends for 3 (Residents #20, #27, and #38) of 6 sampled residents reviewed for personal funds.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 1 (Resident #130) of 3 sampled residents reviewed for preadmission screening and resident review (PASRR).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a person-centered care plan that addressed the exit-seeking behavior for 1 (Resident #47) of 5 sampled residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to clarify a physician order related to a resident's fluid restriction and failed to ensure staff did not provide more than the ordered fluids for 1 (Resident #98) of 2 sampled residents reviewed for dialysis.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medications were not left unattended and the medication cart was not left unlocked with out of sight of the medication nurse for 1 (Cart A Hall A Station 1 medication cart) of 8 medication carts.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBPs) for 1 (Resident #54) of 4 sampled residents reviewed for pressure ulcers and/or urinary catheters.

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive skin assessment on one resident (1) upon return from an Emergency Department (ED) visit after a change of condition As a result, ECG (electrocardiogram-a test that measures electrical activity of the heart; also known as EKG) stickers from a prior ED visit remained undetected on the resident's skin for a period of one week.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) had a written care plan for falls developed that was individualized with resident-specific interventions. In addition, Resident 1's plan of care to prevent falls was not communicated to all staff responsible for care, monitoring, and supervision of the resident. As a result, there was the potential Resident 1 would fall again and be placed at risk for fall-related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff working on the facility's behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior]) had appropriate training, skill sets, and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) to provide appropriate care to the 54 residents on the BHU with mental and psychosocial disorders, and residents experiencing suicidal ideation (SI- thoughts of self-harm and/or the killing oneself). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the necessary behavioral healthcare and services were provided to one of three residents (Resident 1) who was diagnosed with mental disorders (a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior) when: 1. Resident 1's mental disorders and history of suicidal ideation (SI, thoughts of self-harm or of killing oneself), identified upon admission, were care planned with resident-specific interventions to include providing an environment free of items that could be used to inflict self-harm. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's Facility Assessment (determines the resources and training necessary to care for residents competently during the day-to-day operations) failed to: 1. Thoroughly assess its resident population and its ability to provide care for residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of two resident's (Resident 1) physician and/or psychiatrist (a physician who specialized in mental health) when nursing staff observed Resident 1 verbalizing suicidal ideation (SI, thoughts of self-harm or killing oneself). This failure had the potential for Resident 1's change in mental status and/or behavior to go untreated which put the resident at risk for self-harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan intervention was implemented for 1 of 2 residents reviewed for elopement risk. As a result, the well-being of Resident 1 was placed at risk when the resident was able to leave the building unnoticed.

Inspectors wroteBased on interview, and record review, the facility failed to consistently document post (after) dialysis (a procedure for filtering toxins from the blood) assessments for two of two sampled residents (33, 81) and three of seven unsampled residents (49, 79, 96), reviewed for dialysis care. As a result, Resident's 33, 81, 49, 79, and 96 had the potential risk for complications related to delayed assessments from dialysis sessions.

Inspectors wroteBased on record review, facility staff interview, and policy and procedure the facility failed ensure that the following systems were in place for 2 unsampled Residents (35 and 84) out of 4 unsampled Residents and 1 sampled Resident (Resident 54): 1)The facility's medication refrigerated emergency drug kit had not been replaced within 72 hours after opening for the retrieval of one medication for (Resident 54), 2) no expired drugs were available at the facility for administration to any of the facility's residents either in the facility's drug storage rooms or on the facility's medication carts, 3) medications which had been ordered for Resident 35 had been administered as ordered by the resident's physician, and 4) Resident 84's medical record contained documentation indicating why his Gabapentin (Neurontin) had been held. [...]

Inspectors wroteBased on medication room inspection, interview with facility staff, and review of the facility's policies and procedures the facility failed to: 1) ensure that medication room temperatures had been consistently documented on the facility's temperature logs and 2) that the medication refrigerator on Unit 2, had been secured and locked, as outlined in the facility's policies and procedures. This deficiency had the potential for medications to be stored outside of the drug manufacturer's recommendations and creating the possibility of controlled drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to have a consistent method for documenting behaviors and side effects for two of three residents (Residents 54, 577), reviewed psychotropic medications. These failures had the potential for unnecessary medication to be administered when not required, based on the different documentation used for monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices when: 1. The shower curtain in one of three resident shower rooms (Station 2's secured unit), had a dried brown substance on the lower interior (inside) curtain. were left in the shower room; 2. Personal care objects and personal clothing was left in one of three resident shower rooms (Station 2's secured unit), and 3. A urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and tubing was lying on the floor for one (Resident 124) of 2 residents, reviewed for urinary catheter care These failures had the potential for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility did not assure the plan of care for Resident 3's suprapubic catheter (tube inserted into your bladder through a small hole in your belly that drains urine) was implemented for one of three residents (3) with catheters. As a result, Resident 3 had the potential to have a urinary tract infection that was untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 27) received a shower when requested. This failure put the resident at risk for poor hygiene and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents' shower rooms (Station 2's secured unit) was free of hazards when: 1. The shower drain was not covered and was left open and exposed; 2. A wall mounted sharp container was full and not replaced in a timely manner; and, 3. Shaving cream canisters were left in the shower room area. These failures had the potential for residents to injure themselves due to the environmental hazards.

Inspectors wroteBased on observation, interview, and record review the facility did not assure that one of five residents (60) reviewed for unnecessary medications received a medication regimen review (a review that promotes appropriate use of medications and compliance with drug therapy) that provided clinical indication for use and need for gradual dose reduction of Resident 60's Seroquel (mood altering medication used for schizophrenia [a disorder that affects a person 's ability to think, feel, and behave clearly]). As a result, Resident 60 potentially suffered side-effects of Seroquel that was not indicated for use in the resident's medical condition.

Inspectors wroteBased on observation, interview, and record review the facility did not assure one of five residents (60) reviewed for unnecessary medication use received: 1. A psychiatric clinical assessment for a diagnosis of Schizophrenia (inappropriate behaviors and thought processes) 2. Monitoring for side effects such as sedation related to the use of Seroquel (antipsychotic (mind altering) medication used to treat certain mental conditions such as schizophrenia). As a result, Resident 60 received a drug that was not indicated for the resident's condition and was sedated for large amounts of time.

Inspectors wroteBased on record review, facility staff interview, and policies and procedures the facility had failed to ensure that 1 unsampled Resident (16) of 4 unsampled Residents reviewed, were free of any significant medication errors during the Medication Pass Observation process on 7/12/2022 between 8:30 am and 10:30 am. This medication error had the potential to require that this resident be sent back to the hospital for the treatment of Atrial Fibrillation (A-Fib), an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart. A-fib increases the risk of stroke, heart failure and other heart-related complications which could have also potentially led to this resident's death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. The kitchen dish washers did not know how to correctly test PPM (parts per million) concentration of the dishwashing solution with the chlorine test strip. 2. Kitchen staff did not follow the facility policy and procedure for fortifying resident diets. These failures had the potential to expose 120 residents who consume food from the kitchen to practices associated with the transmission of foodborne illness.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to follow the facility's policy related to recipes and therapeutic menus as planned. This failure had the potential to result in weight loss of 120 of 126 residents who consumed food from the kitchen due to reduced food intake, and may have further compromised their nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain sanitary kitchen equipment, safe, proper storage and handling of food practices, were met when: 1. A resident's refrigerator temperature was not within a safe temperature range; 2. A can opener had a build-up black colored substance and residue on it; 3. A utensil storage bin had a build-up of unknown particles and dust; and 4. Expired foods were found in the refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses for residents in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to implement their policy and procedure related to food brought from the outside to residents for one of two residents' refrigerators when the food inside the refrigerator were not labeled or dated, and expired food was not discarded. In addition, the resident refrigerator temperature was not within a safe range for food storage. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a ceiling suspended privacy curtain, which extended around the bed to provide visual privacy, was provided to one of three residents (Resident 122), reviewed for privacy. This deficient practice violated Resident 122's right to privacy and had the potential for the resident to be exposed to others during personal care.

Inspectors wroteBased on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure appropriate departmental supervision and oversight of dietary operations with adequate supervisory staff in the kitchen. This repeated failure to ensure effective oversight of day to day food and nutrition operations may place residents at nutritional risk from exposure to unsanitary practices, and in turn, further compromise their health status. The facility census was 167. (Cross reference F801, F804, F812, F813, F908, and F925)

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary conditions were met food service and storage, in and out of the Food and Nutrition Services department when: 1) Expired PHF/TCS food items were stored in a reach-in refrigerator, 2) Three staff were not wearing a beard cover and two did not wear a hairnet, 3) Ice machine bin was dirty, 4) Safe food storage conditions were not met for the dry food storage room 5) Dirty, worn down cooking utensils were stored in a drawer with clean utensils 6) Unit refrigerators with resident food were dirty with caked on brown-blackish grime inside the door shelves and racks These failures had the potential to cause widespread foodborne illness in 165 of 167 facility residents who consumed food from the Food and Nutrition Services Department.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food for residents was prepared in a manner that conserved flavor, appearance, attractiveness, and nutritive value. This repeated failure had the potential to affect the meal intake, overall nutritional status, and lead to unintentional weight loss in 48 residents who received a regular, pureed, or mechanical soft diet. (cross reference F801)

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary practices were followed for residents' food brought in from outside the facility. Failure to ensure safe storage and reheating procedures for residents' food brought in from the outside had the potential to result in widespread foodborne illness for 167 residents in the facility.

Inspectors wroteBased on observation, review of the facility assessment plan, and staff interviews, the facility failed to accurately assess the competency of its food and nutrition services supervisory staff and ensure adequate supervisory oversight in the kitchen at all times. This deficient practice had the potential to cause food borne illness and inadequate intake of nutrients for 167 residents who consumed food or received nutrition support from the facility. (cross reference F801, F804, F812, F813, F908, F925)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential kitchen equipment, including a walk-in freezer, was in safe operating condition according to standards of practice. This repeated deficient failure had the potential to cause contamination in food storage and sanitation equipment, which could affect overall foodservice operations. The facility census was 167.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Four confidential residents (A, B, C, and D) received hair cutting services regularly and, 2. Six confidential residents (A, C, D, E, F, and G) received showers regularly. These failures had the potential to result in a lack of dignity and feelings of low self esteem in the residents.

Inspectors wroteBased on observation, interview and record review, the facility did not develop a care plan for two of four sampled residents (8, 70) when: 1. Resident 8 did not have a care plan for the use of a Fentanyl patch (a strong narcotic drug applied to the skin which is used to treat severe pain). 2. Resident 70's care plan did not include interventions for turning and repositioning. This failure had the potential for miscommunication between staff members which could lead to harm.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the development of a pressure injury for one of four residents reviewed for pressure injury (154). This failure resulted in Resident 154 experiencing pain and skin breakdown of her right cheek.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a suprapubic catheter (a device that is inserted into a bladder to drain urine) was changed for one of three residents (37) reviewed for catheters. This failure had the potential for increased risk of infection, and obstruction within the catheter tubing. Resident 37 was admitted to the facility on [DATE], with diagnoses which included Multiple Sclerosis (disease where nerve cells in the brain and spinal cord are damaged) and neuromuscular dysfunction of the bladder (bladder muscles do not function), per the facility's Admissionrecord. During an interview on 2/5/19 at 9:15 A.M., Resident 37 stated she didn't feel her catheter was being changed enough. Resident 37 stated she thought it was monthly and felt it had not been changed in well over a month. A record review was conducted on 2/6/19 at 2:44 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure one resident's medication was labeled with resident specific information. The lack of labeling created the potential for inappropriate use of the medication and/or use by another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained in the Dietary Services department. This failure had the potential to contaminate food stored in the dining area and could cause widespread foodborne illness.